NURSING CARE DURING PRENATAL PERIOD I. ASSESSMENT

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

A. Nursing Health History 1. Estimation of EDC, AOG, LMP, FH, Naegeles 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) Naegeles Rule For LMP between April to December: - 3 (months) +7 (days) +1 (Year)

Bartholomews Rule estimates AOGby the relative position of the uterus in the abdominal cavity AOG 12 weeks 20 weeks 36 weeks 32 and 40 weeks Anatomical Landmark: Slightly above the symphysis pubis Level of the umbilicus Below the xiphoid process Same level due to lightening on the 40th week

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 - 31 February - 14 ______________________ 60 days / 7 = 8 weeks and 4 days (AOG) Mc Donalds Rule

2. OB Classification: Gravida; Para; Full term; AbortionObstetrical 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 Assessment 1. Leopolds Maneuver Purpose: to estimate fetal size, locate fetal parts and determine presentation, position, engagement and attitude LM1: fetal presentation LM2: fetal position LM3: fetal engagement LM4: 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 clients hips. 2. Vital signs (BP)/ Weight 3. Fetal assessment: FHR; Fetal Movement Normal Fetal Heart Tone: 120-160 BPM Number of Fetal movement every 10 minutes: 2 for every 10 minutes Number of Fetal movement every hour: 10-12 per hour *DIAGNOSIS OF PREGNANCYSTAGE PRESUMPTIVE PROBABLE POSITIVE

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 patients upper body during the test to PREVENT COMPRESSION OF VENA CAVA Amniocentesis It is a procedure used to obtain amniotic fluid for testing

First Amenorrhea Chadwicks Ultrasound Trimester Morning signs evidence sickness Goodells sign Breast changes Hegars sign Fatigue Positive HCG Urinary (pregnancy frequency test) Enlarging uterus Elevation of BBT Second Quickening trimester Increased skin pigmentation; (chloasma and linea nigra) Striae gravidarum Enlarged Fetal heart tone abdomen Fetal movement Braxton Hicks felt by the Contraction examiner Ballotement Fetal outline on X-ray

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.

C. Laboratory tests Urine Heat acetic- ALBUMINURIA Benedicts tests- GLYCOSURIA Urinalysis- UTI Blood CBC (Hgb, Hct)- ANEMIA Blood typing VDRL- SYPHILIS

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 on 1. 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

4.Ultrasound

Diagnostic Tests

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

Two types: A. Transabdominal B. Transvaginal Nursing Responsibilities:

2. Fetal lung maturity Assesses for:

1. Drink 1- 1.5 quart of water 2 hoursbefore the procedure

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

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

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

1.

2. Instruct to engage to LIGHTACTIVITY 24 HOURS after the test Rationale: to decrease uterine irritability 3. Increase fluid intake Rationale: to increase uteroplacental 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

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. Reactive

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.

If two accelerations of FHR (15 beats or more) lasting for 15 seconds occur after fetal movement B. Non reactive If no acceleration occurs with fetal movement or no fetal movement Biophysical Profile (BPP) Comprehensive assessment of five biophysical variables: 1. f etal breathing movement 2. f etal movements of body or limbs 3. f etal tone (extension or flexion of extremities) 4. a mniotic fluid volume (visualized as pockets of fluids around the fetus) 5. r eactive 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)Component

Indication of BPP: (at risk of placental insufficiency or fetal compromise because of the following: 4. Intrauterine growth restriction (IUGR) 5. Maternal DM 6. Maternal heart disease 7. Maternal chronic HPN/ Preeclampsia/ eclampsia 8. Maternal sickle cell anemia 9. Suspected fetal post maturity 10. History of previous still births 11. Rh sensitization 12. Abnormal estriol excretion 13. Hypeethyroidi sm 14. Renal disease 15. Nonreactive NST Chorionic Villi Sampling Invol ves obtaining a small sample of chorionic villi from the developing placenta

1 trimester diagnosis of genetic, metabolic, and DNA studiesst

For

Fetal breathing movement Fetal movements of body or limbs

Fetal tone

Amniotic fluid volume Non stress Test

Normal (score= 2) 1 episode of rhythmic breathing lasting 30 seconds within 30 minutes 3 discrete body or limb movements in 30 minutes (episodes of active continuous movement considered as single movement) 1 episode of extension of a fetal extremity with return to flexion, or opening or closing of hand 2 accelerations of 15 beats/min for 15 seconds in 20 minutes Single vertical pocket > 2 cm

Abnormal (score= 0) 30 seconds of breathing in 30 minutes 2 movements in 30 minutes

Can be performed either transabdominally or transcervically Perfo rmed between 10 and 12 weeks; thus it can not detect neural tube defect

No movements or extension/flexion

0-1 acceleration in 20 minutes Largest single vertical pocket 2 cm

of CVS include: 6. ailure to obtain tissue 7. upture of membranes

Risk F R L B I M R

8.eakage of amniotic fluid 9. leeding 10. ntrauterine infection 11. aternal tissue contamination of the specimen 12. h alloimmunization

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.

13. pontaneous abortion II. Diagnosis Wellness diagnosis Knowledge Deficit Altered Health Maintenance Nutrition, less than required

S

Advise 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

III.

Planning/ Implementation/ Evaluation 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 Supplement 1. Folic acid 2. Iron H. Managing Discomforts of Pregnancy G. Clothing Use of abdominal support such as light maternity girdle for support not to compress and constrict the abdomen Avoid knee high stockings H. Sexual Activity Contraindicated: 1. Women with history of abortion 2. Rupture membrane 3. Vaginal spotting I. Prenatal visit Start 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

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 Exercises 1. 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 (Kegels) -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. Hygiene If membranes rupture or vaginal bleeding is present or during the last month of pregnancy, tub baths are contraindicated. D. Travel