NURSING CARE DURING PRENATAL PERIOD

I. ASSESSMENT

A. Nursing Health History1. Estimation of EDC, AOG, LMP, FH,

Naegele’s Rule, Weight

Determining the Last Menstual Period (LMP) First day of last menstruation

Example: Last menstruation= June 14-18, 2008

LMP: June 14, 2008

Determining the Expected date of delivery (EDC)A. Naegele’s Rule

For LMP between April to December: - 3 (months) +7 (days) +1 (Year)

For LMP betwen January to March:+ 9 (months) +7 (days)

Examples: 1. LMP : January 15, 2005

01 15 2005 + 9 +7

__________________ 10 22 2005 (October 22, 2005)

2. LMP : December 16 2004

12 16 2004 -03 +7 +1

__________________ 09 23 2005 (September 23, 2005)

Determining the Age of Gestation (AOG) Number of days since LMP to the present

day divided by 7

Example:A pregnant woman comes to the clinic for an initial prenatal check up. Her LMP was December 16, 2004. Present day is February 14, 2005.

December - 15 (31 days – 16 days)January - 31February - 14______________________ 60 days / 7 = 8 weeks and 4

days (AOG)

Mc Donald’s Rule Formula: AOG (months)= Fundic height

(in cm)÷ 4

E.g. FH of 24 cm = 24 ÷ 4

= 6 months (24 weeks)

***For 20 weeks AOG and above:FUNDIC HEIGHT (CM) = AOG (WEEKS)

**For below 20 weeks AOG:= FH (CM) x 8 / 7= AOG in weeks

Bartholomew’s Rule – estimates AOG by the relative position of the uterus in the abdominal cavity

2. OB Classification: Gravida; Para; Full term; Abortion

Obstetrical Scoring (GP TPALM)

Gravida- number of pregnancy (including present pregnancy)

Parity- number of viable pregnancies who are previously born/ number of viable deliveries

Term- number of children born between 37- 42 weeks AOG

Preterm- number of children born before the 37th week of gestation

Abortion- pregnancy that did not reach the age of viability (> 20 weeks AOG or < 400g)

Living- number of CURRENTLY living children

Multiple Pregnancies- (i.e. twins, triplets are counted as one)

B. Physical Assessment1. Leopold’s ManeuverPurpose: to estimate fetal size, locate fetal parts and determine presentation, position, engagement and attitudeLM1: fetal presentationLM2: fetal positionLM3: fetal engagementLM4: fetal attitude

Position: dorsal recumbent position

Preparation: 1. The client must empty her bladder 30 minutes before examination; 2. Place a small pillow underneath the client’s hips.

2. Vital signs (BP)/ Weight

AOG Anatomical Landmark:12 weeks Slightly above the symphysis pubis20 weeks Level of the umbilicus36 weeks Below the xiphoid process32 and 40 weeks Same level due to lightening on the

40th week

3. Fetal assessment: FHR; Fetal MovementNormal Fetal Heart Tone: 120-160 BPMNumber of Fetal movement every 10 minutes:

2 for every 10 minutes Number of Fetal movement every hour:

10-12 per hour

*DIAGNOSIS OF PREGNANCY

STAGE PRESUMPTIVE PROBABLE POSITIVE

First Trimester

AmenorrheaMorning

sicknessBreast changesFatigueUrinary

frequencyEnlarging uterus

Chadwick’s signs

Goodell’s signHegar’s signPositive HCG (pregnancy test)Elevation of BBT

Ultrasound evidence

Second trimester

QuickeningIncreased skin

pigmentation; (chloasma and

linea nigra)Striae

gravidarum 

Enlarged abdomenBraxton HicksContractionBallotement

Fetal heart toneFetal movement felt by the examinerFetal outline on X-ray

C. Laboratory tests Urine

Heat acetic- ALBUMINURIA Benedict’s tests- GLYCOSURIA Urinalysis- UTI

Blood CBC (Hgb, Hct)- ANEMIA Blood typing VDRL- SYPHILIS

4. Diagnostic Tests

Ultrasound

Intermittent ultrasonic waves are transmitted by an alternating current to a transducer, which is applied to the women’s abdomen

Two types: A. Transabdominal

B. Transvaginal

Nursing Responsibilities: 1. Drink 1- 1.5 quart of water 2 hours

before the procedure

2. Instruct the client not to void Rationale: Fills the urinary bladder and

moves it upward and away from the uterus; when the bladder is full, the examiner can assess other structures,

especially the vagina, cervix, in relation to the bladder

3. Position: Supine If the client complains of dizziness or

shortness of breath:A. Place the patient on side lying

position with towel under hip B. Elevate the patient’s upper body

during the test to PREVENT COMPRESSION OF VENA CAVA

Amniocentesis

It is a procedure used to obtain amniotic fluid for testing

The physician scans the uterus using ultrasound to identify the fetal and placental positions to identify adequate amount of amniotic fluids.

The skin is cleaned with betadine; local anesthesia at the needle insertion is optional; gauge 22 needle is then inserted into the uterine cavity and amniotic fluid is withdrawn.

Obtain 15-20 cc of amniotic fluid for examination

Should not be done until at least 16 weeks of gestation

A. Diagnostic Uses: Provides information on1. Fetal Health Assesses appropriate levels of:

a. Alpha- fetoprotein (AFP)b. Human chorionic gonadotropin

(HCG)c. Unconjugated estriol (UE)

Necessary for detection of DOWN SYNDROME (TRISOMY 21), TRISOMY 18, and NEURAL TUBE DEFECT

2. Fetal lung maturity Assesses for:

a. Lecithin/ Sphingomyelin (L/S) ratio-surfactant

**By 35 weeks AOG, the normal L/S ratio= 2:1; decrease risk of acquiring Respiratory Distress Syndrome

b. Phosphatidylglycerol (PG)- phospholipid in surfactant

**Appears when fetal lung maturity has been attained at about 35

weeks AOG, must be present to prevent RDS

3. Genetic disorders

Nursing Responsibilities :1. Monitor for the side effects: Unusual fetal hyperactivity or lack of

movement Clear vaginal discharge/ Bleeding Uterine contraction or abdominal pain Fever or chills

2. Instruct to engage to LIGHT ACTIVITY 24 HOURS after the test

Rationale: to decrease uterine irritability

3. Increase fluid intake Rationale: to increase utero-placental

circulation and replace amniotic fluid

Contraction Stress Test (CST) Means of evaluating the respiratory function

(oxygen and carbon dioxide exchange) of the placenta

Identifies the fetus at risk for intrauterine asphyxia by observing the response of the FHR to the stress of uterine contractions (spontaneous or induced)

Procedure 1. The critical component of CST is the

presence of uterine contractions. They may occur spontaneously or may be induced with oxytocin administered via IV (also known as oxytocin challenge test). The natural way of obtaining oxytocin is through nipple stimulation.

2. An electronic fetal monitor is used to provide continuous data about the fetal heart rate and uterine contractions.

3. After 15 minutes of baseline recording of uterine activity and FHR, the tracing is evaluated for presence of spontaneous contractions. If 3 spontaneous contractions of good quality and lasting 40-60 seconds occur in a 10 minute window, the results are evaluated. If no contractions occur or they are insufficient for interpretation, oxytocin is administered via IV or the breasts are stimulated.

Interpretation 1. Negative (normal/ desired result)

3 contractions of good quality lasting 40 seconds or more in 10 minutes

without evidence of late decelerations

Implies that the fetus can handle the hypoxic stress of uterine contractions

2. Positive (Abnormal result) Repetitive late decelerations with

more than 50% of the contractions Implies that the hypoxic stress of

contraction causes a slowing of the FHR

3. Equivocal/ Suspicious Non-persistent late decelerations or

decelerations associated with hyper-stimulation (contractions frequency every 2 minutes or duration of longer than 90 seconds

Nonstress Test measures the response of the fetal heart

rate to fetal movement Instruct the mother to push the button

attached to uterine contraction monitor if she feels the fetus moves

Usually done for 10-20 minutes

What happens to the FHT if fetal movement occurs?As the fetus moves, there is an INCREASE in FHT (15 beats per minute) and remains elevated for 15 seconds

Results and Interpretation:A. ReactiveIf two accelerations of FHR (15 beats or more) lasting for 15 seconds occur after fetal movement

B. Non reactiveIf no acceleration occurs with fetal movement or no fetal movement

Biophysical Profile (BPP) Comprehensive assessment of five

biophysical variables:1. fetal breathing movement2. fetal movements of body or limbs3. fetal tone (extension or flexion of

extremities)4. amniotic fluid volume (visualized as

pockets of fluids around the fetus)5. reactive FHR with activity (reactive

NST)

The first 4 variables are assessed by UTZ scanning. FHR reactivity is assessed with the NST.

Determines the compromised fetus or confirms the healthy fetus

(Criteria for BPP Scoring)

A score of 2 is assigned to each normal finding and 0 to each abnormal one, for a maximum score of 10.

Score of 8 (with normal amniotic fluid) and 10 are considered normal.

Indication of BPP: (at risk of placental insufficiency or fetal compromise because of the following:4. Intrauterine growth restriction (IUGR)5. Maternal DM6. Maternal heart disease7. Maternal chronic HPN/ Preeclampsia/

eclampsia8. Maternal sickle cell anemia9. Suspected fetal post maturity10. History of previous still births11. Rh sensitization12. Abnormal estriol excretion13. Hypeethyroidism14. Renal disease15. Nonreactive NST

Chorionic Villi Sampling Involves obtaining a small sample of

chorionic villi from the developing placenta

For 1st trimester diagnosis of genetic, metabolic, and DNA studies

Can be performed either transabdominally or transcervically

Performed between 10 and 12 weeks; thus it can not detect neural tube defect

Risk of CVS include:6. Failure to obtain tissue7. Rupture of membranes8. Leakage of amniotic fluid9. Bleeding

10. Intrauterine infection11. Maternal tissue contamination of the

specimen12. Rh alloimmunization13. Spontaneous abortion

II. DiagnosisWellness diagnosisKnowledge DeficitAltered Health MaintenanceNutrition, less than required

III. Planning/ Implementation/ Evaluation

A. Nutrition – most important aspect*Nutritional assessment is

based on taking a diet history first:

1. food preferences/ eating habits

2. cultural/religious influences

3. occupation/educational level

B. Prenatal Exercises1. Tailor sitting

-stretches and strengthen perineal muscles; increase circulation in the perineum; make pelvic joints more pliable

2. Pelvic rock-maintains good posture; relieves abdominal pressure and low backache; strengthens abdominal muscles following delivery

3. Squatting -stretches the pelvic floor muscle; should be done15 minutes daily

4. Pelvic Floor Contraction (Kegel’s)-promotes perineal healing; relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles `

5. Abdominal Contractions-strengthens abdominal muscle during pregnancy and prevents constipation in the postpartal period

Walking is the best exercise during pregnancy

Jogging is questionable because of the strain of extra weight of pregnancy placed on the knees

C. HygieneIf membranes rupture or vaginal bleeding is present or during the last month of pregnancy, tub baths are contraindicated.

Component Normal (score= 2) Abnormal (score= 0)

Fetal breathing movement

≥ 1 episode of rhythmic breathing lasting ≥ 30 seconds within 30 minutes

≤ 30 seconds of breathing in 30 minutes

Fetal movements of body or limbs

≥ 3 discrete body or limb movements in 30 minutes (episodes of active continuous movement considered as single movement)

≤ 2 movements in 30 minutes

Fetal tone ≥ 1 episode of extension of a fetal extremity with return to flexion, or opening or closing of hand

No movements or extension/flexion

Amniotic fluid volume

≥ 2 accelerations of ≥ 15 beats/min for ≥ 15 seconds in 20 minutes

0-1 acceleration in 20 minutes

Non stress Test Single vertical pocket > 2 cm

Largest single vertical pocket ≤ 2 cm

D. TravelAdvise a woman who is taking a long trip by automobile to plan for frequent rest or stretch period

At least every 2 hours, she should get out of the car and walk a short distance

Use of seat belt is advised (shoulder harness and lap belts)

Infant car seat should be purchased

Traveling by plane is not contraindicated as long as plane is pressurized. If more than 7 months, traveling by plane is not recommended.

F. Immunization –Tetanus Toxoid

G. Nutritional Supplement1. Folic acid2. Iron

H. Managing Discomforts of Pregnancy

G. ClothingUse of abdominal support such as light maternity girdle for support not to compress and constrict the abdomen

Avoid knee high stockings H. Sexual ActivityContraindicated:1. Women with history of abortion 2. Rupture membrane 3. Vaginal spotting

I. Prenatal visitStart of pregnancy – 32 weeks

Every month

On 32-36 weeks AOG Every 2 weeks/twice a month

On 36 weeks AOG Every week until labor pains set in