NURSING CARE DURING PRENATAL PERIOD I. ASSESSMENT A. Nur sing Health Histor y 1. Estimation of EDC, AOG, LMP, FH, Naegele’s Rule, Weight Deter mining the Last Menstual Per iod (LMP) Fir st day of last menstr uation Example: Last menstr uation= June 14-18, 2008 LMP: June 14, 2008 Deter mining the Expected date of deliver y (EDC) A. Naegele’s Rule For LMP between Apr il to December : - 3 (months) +7 (days) +1 (Year ) For LMP betwen Januar y to Mar ch: + 9 (months) +7 (days) Examples: 1. LMP : Januar y 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) Deter mining the Age of Gestation (AOG) Number of days since LMP to the pr esent day divided by 7 Example: A pr egnant woman comes to the clinic f or an initial pr enatal check up. Her LMP was December 16, 2004. Pr esent day is Febr uar y 14, 2005. December - 15 (31 days – 16 days) Januar y - 31 Febr uar y - 14 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 60 days / 7 = 8 weeks and 4 days (AOG) Mc Donald’s Rule For mula: AOG (months)= Fundic height (in cm)÷ 4 E.g. FH of 24 cm = 24 ÷ 4 = 6 months (24 weeks) ** * F or 2 0 w eek s AOG and abov e: FUNDIC HEIGHT (CM) = AOG (WEEKS) * * F or bel ow 2 0 w eek s AOG: = FH (CM) x 8 / 7 = AOG in weeks
Bar tholomew’s Rule – estimates AOG by the r elative position of the uter us in the abdominal cavity AO G 12 weeks 20 weeks 36 weeks 32 and 40 weeks
Anat omi c al Land mar k : Slightly above the symphysis pubis Level of the umbilicus Below the xiphoid pr ocess Same level due to lightening on the 40th week
2. OB Classif ication: Gr avida; Par a; Full ter m; Abor tion Obstetr ical Scor ing (GP TPALM)
Gr avida- number of pr egnancy (including pr esent pr egnancy) Par ity- number of viable pr egnancies who ar e pr eviously bor n/ number of viable deliver ies Ter m- number of childr en bor n between 37- 42 weeks AOG Pr eter m- number of childr en bor n bef or e the 37th week of gestation Abor tion- pr egnancy that did not r each the age of viability (> 20 weeks AOG or < 400g) Living- number of CURRENTLY living childr en Multiple Pr egnancies- (i.e. twins, tr iplets ar e counted as one)
B. Physical Assessment 1. Leopold’s Maneuver Pur pose: to estimate f etal size, locate f etal par ts and deter mine pr esentation, attitude LM1: f etal pr esentation LM2: f etal position LM3: f etal engagement LM4: f etal attitude
position,
Position: dor sal r ecumbent position Pr epar ation: 1. The client must empty her bladder 30 minutes bef or e examination; 2. Place a small pillow under neath the client’s hips. 2. Vital signs (BP) / Weight 3. Fetal assessment: FHR; Fetal Movement Nor mal Fetal Hear t Tone: 120-160 BPM Number of Fetal movement ever y 10 minutes: 2 f or ever y 10 minutes Number of Fetal movement ever y hour : 10-12 per hour *DIAGNOSIS OF PREGNANC Y Labor ator y tests Ur ine Heat acetic- ALBUMINURIA Benedict’s tests- GLYCOSURIA Ur inalysis- UTI Blood CBC (Hgb, Hct)- ANEMIA Blood typing VDRL- SYPHILIS
engagement
and
ST AGE
PRESUMPTIVE
PROBABLE
POSITIVE
Fir st Tr imester Amenor r hea Mor ning sickness Br east changes Fatigue Ur inar y f r equenc y Enlar ging uter us
Chadwick’s signs Goodell’s sign Hegar ’s sign Positive HCG (pr egnancy test) Elevation of BBT
Ultr asound evidence
Second tr imester
Enlar ged abdomen Br axton Hicks Contr action Ballotement
Fetal hear t tone Fetal movement f elt by the examiner Fetal outline on X-r ay
Quickening Incr eased skin pigmentation; (chloasma and linea nigr a) Str iae gr avidar um
4. Diagnostic Tests Ultr asound Inter mittent ultr asonic waves ar e tr ansmitted by an alter nating cur r ent to a tr ansducer , which is applied to the women’s abdomen Two types: A. Tr ansabdominal B. Tr ansvaginal N u r si ng R es ponsi bi l i t i es: 1. Dr ink 1- 1.5 quar t of water 2 hour s bef or e the pr ocedur e 2. Instr uct the client not to void Rationale: Fills the ur inar y bladder and moves it upwar d and away f r om the uter us; when the bladder is f ull, the examiner can assess other str uctur es, especially the vagina, cer vix, in r elation to the bladder 3. Position: Supine If the client complains of dizziness or shor tness of br eath: A. Place the patient on side lying position with towel under hip B. Elevate the patient’s upper body dur ing the test to PREVENT COMPRESSION OF VENA CAVA Amniocentesis
It is a pr ocedur e used to obtain amniotic f luid f or testing The physician scans the uter us using ultr asound to identif y the f etal and placental positions to identif y adequate amount of amniotic f luids. The skin is cleaned with betadine; local anesthesia at the needle inser tion is optional; gauge 22 needle is then inser ted into the uter ine cavity and amniotic f luid is withdr awn. Obtain 15-20 cc of amniotic f luid f or examination Should not be done until at least 16 weeks of gestation
A. Diagnostic Uses: Pr ovides inf or mation on 1. Fetal Health Assesses appr opr iate levels of : a. Alpha- f etopr otein (AFP) b. Human chor ionic gonadotr opin (HCG) c. Uncon jugated estr iol (UE) Necessar y f or detection of DOWN SYNDROME (TRISOMY 21), TRISOMY 18, and NEURAL TUBE DEFECT 2. Fetal lung matur ity Assesses f or : a. Lecithin/ Sphingomyelin (L/S) r atio-sur f actant **By 35 weeks AOG, the nor mal L/S r atio= 2:1; decr ease r isk of acquir ing Respir ator y Distr ess Syndr ome b. Phosphatidylglycer ol (PG)- phospholipid in sur f actant **Appear s when f etal lung matur ity has been attained at about 35 weeks AOG, must be pr esent to pr event RDS 3. Genetic disor der s N u r si ng R es ponsi bi l i t i es: 1. Monitor f or the side ef f ects: Unusual f etal hyper activity or lack of movement Clear vaginal dischar ge/ Bleeding Uter ine contr action or abdominal pain Fever or chills 2. Instr uct to engage to LIGHT ACTIVITY 24 HOURS af ter the test Rationale: to decr ease uter ine ir r itability 3. Incr ease f luid intake Rationale: to incr ease uter o-placental cir culation and r eplace amniotic f luid
Contr action Str ess Test (CST) Means of evaluating the r espir ator y f unction (oxygen and car bon dioxide exchange) of the placenta Identif ies the f etus at r isk f or intr auter ine asphyxia by obser ving the r esponse of the FHR to the str ess of uter ine contr actions (spontaneous or induced) P r oc ed u r e 1. The cr itical component of CST is the pr esenc e of ut er i ne c ont r ac t i ons. They may occur spontaneously or may be induced with oxytocin administer ed via IV (al so k now n as o x y t oc i n c hal l eng e t es ) t . The natur al way of obtaining oxytocin is thr ough nipple stimulation. 2. An electr onic f etal monitor is used to pr ovide continuous data about the f etal hear t r ate and uter ine contr actions. 3. Af ter 15 minutes of baseline r ecor ding of uter ine activity and FHR, the tr acing is evaluated f or pr esence of spontaneous contr actions. If 3 spontaneous contr actions of good quality and lasting 40-60 seconds occur in a 10 minute window, the r esults ar e evaluated. If no contr actions occur or they ar e insuf f icient f or inter pr etation, oxytocin is administer ed via IV or the br easts ar e stimulated.
I nt er pr et at i on 1. Negative (nor ma / l desir ed r esult) 3 contr actions of good quality lasting 40 seconds or mor e in 10 minutes without evidence of late deceler ations Implies that the f etus can handle the hypoxic str ess of uter ine contr actions 2. Positive (Abnor mal r esult) Repetitive late deceler ations with mor e than 50% of the contr actions Implies that the hypoxic str ess of contr action causes a slowing of the FHR
3. Equivoca / l Suspicious Non-per sistent late deceler ations or deceler ations associated with hyper -stimulation (contr actions f r equency ever y 2 minutes or dur ation of longer than 90 seconds
Nonstr ess Test measur es the r esponse of the f etal hear t r ate to f etal movement Instr uct the mother to push the button attached to uter ine contr action monitor if she f eels the f etus moves Usually done f or 10-20 minutes What happens to the FHT if f etal movement occur s? As the f etus moves, ther e is an INCREASE in FHT (15 beats per minute) and r emains elevated f or 15 seconds Results and Inter pr etation: A. Reactive If two acceler ations of FHR (15 beats or mor e) lasting f or 15 seconds occur af ter f etal movement B. Non r eactive If no acceler ation occur s with f etal movement or no f etal movement Biophysical Pr of ile (BPP) Compr ehensive assessment of f ive biophysical var iables: 1. f etal br eathing movement 2. f etal movements of body or limbs 3. f etal tone (extension or f lexion of extr emities) 4. amniotic f luid volume (visualized as pockets of f luids ar ound the f etus) 5. r eactive FHR with activity (r eactive NST) The f ir st 4 var iables ar e assessed by UTZ scanning. FHR r eactivity is assessed with the NST. Deter mines the compr omised f etus or conf ir ms the healthy f etus (Cr iter ia f or BPP Scor ing) Component
Fetal br eathing movement Fetal movements of body or limbs
Fetal tone
Amniotic f luid volume Non str ess Test
Nor mal (scor e= 2) ≥ 1 episode of r hythmic br eathing lasting ≥ 30 seconds within 30 minutes ≥ 3 discr ete body or limb movements in 30 minutes (episodes of active continuous movement consider ed as single movement) ≥ 1 episode of extension of a f etal extr emity with r etur n to f lexion, or opening or closing of hand ≥ 2 acceler ations of ≥ 15 beats/min f or ≥ 15 seconds in 20 minutes Single ver tical pocket > 2 cm
Abnor mal (scor e= 0) ≤ 30 seconds of br eathing in 30 minutes ≤ 2 movements in 30 minutes
No movements or extension/f lexion
0-1 acceler ation in 20 minutes
Lar gest single ver tical pocket ≤ 2 cm
A scor e of 2 is assigned to each nor mal f inding and 0 to each abnor mal one, f or a maximum scor e of 10. Scor e of 8 (with nor mal amniotic f luid) and 10 ar e consider ed nor mal.
Indication of BPP: (at r isk of placental insuf f iciency or f etal compr omise because of the f ollowing: 4. Intr auter ine gr owth r estr iction (IUGR) 5. Mater nal DM 6. Mater nal hear t disease 7. Mater nal chr onic HPN/ Pr eeclampsia/ eclampsia 8. Mater nal sickle cell anemia 9. Suspected f etal post matur ity 10. Histor y of pr evious still bir ths 11. Rh sensitization 12. Abnor mal estr iol excr etion 13. Hypeethyr oidism 14. Renal disease 15. Nonr eactive NST Chor ionic Villi Sampling Involves obtaining a small sample of chor ionic villi f r om the developing placenta st For 1 tr imester diagnosis of genetic, metabolic, and DNA studies Can be per f or med either tr ansabdominally or tr anscer vically Per f or med between 10 and 12 weeks; thus it can not detect neur al tube def ect
Risk of CVS include: 6. Failur e to obtain tissue 7. Ruptur e of membr anes
8. Leakage of amniotic f luid 9. Bleeding 10. Intr auter ine inf ection 11. Mater nal tissue contamination of the specimen 12. Rh alloimmunization 13. Spontaneous abor tion II. Diagnosis: Wellness diagnosis Knowledge Def icit Alter ed Health Maintenance Nutr ition, less than r equir ed III. Planning / Implementation / Evaluation A. Nutr ition – most impor tant aspect *Nutr itional assessment is based on taking a diet histor y f ir st: 1. f ood pr ef er ences/ eating habits 2. cultur al/r eligious inf luences 3. occupation/educational level B. Pr enatal Exer cises 1. Tailor sitting -str etches and str engthen per ineal muscles; incr ease cir culation in the per ineum; make pelvic joints mor e pliable 2. Pelvic r ock -maintains good postur e; r elieves abdominal pr essur e and low backache; str engthens abdominal muscles f ollowing deliver y 3. Squatting -str etches the pelvic f loor muscle; should be done15 minutes daily 4. Pelvic Floor Contr action (Kegel’s) -pr omotes per ineal healing; r elieves congestion and discomf or t in pelvic region; tones up pelvic f loor muscles `
5. Abdominal Contr actions -str engthens abdominal muscle dur ing pr egnancy and pr events constipation in the postpar tal per iod Walking is the best exer cise dur ing pr egnancy Jogging is questionable because of the str ain of extr a weight of pr egnancy placed on the knees C. Hygiene If membr anes r uptur e or vaginal bleeding is pr esent or dur ing the last month of pr egnancy, tub baths ar e contr aindicated. D. Tr avel Advise a woman who is taking a long tr ip by automobile to plan f or f r equent r est or str etch per iod At least ever y 2 hour s, she should get out of the car and walk a shor t distance Use of seat belt is advised (shoulder har ness and lap belts) Inf ant car seat should be pur chased Tr aveling by plane is not contr aindicated as long as plane is pr essur ized. If mor e than 7 months, tr aveling by plane is not r ecommended. F. Immunization –Tetanus Toxoid G. Nutr itional Supplement 1. Folic acid 2. Ir on H. Managing Discomf or ts of Pr egnancy G. Clothing Use of abdominal suppor t such as light mater nity gir dle f or suppor t not to compr ess and constr ict the abdomen Avoid knee high stockings H. Sexual Activity Contr aindicated: 1. Women with histor y of abor tion 2. Ruptur e membr ane 3. Vaginal spotting I. Pr enatal visit Star t of pr egnancy – 32 weeks Ever y month On 32-36 weeks AOG Ever y 2 weeks/twice a month On 36 weeks AOG Ever y week until labor pains set in Scor es 3 and below ar e gener ally r egar ded as cr itically low, 4 to 6 f air ly low, and 7 to 10 gener ally nor mal. Scor e of 0
Scor e of 1
Scor e of 2
Component of acr onym
Skin color /Complexion
blue or pale all over
blue at extr emities bod y pink (acr ocyanosis)
no cyanosis bod y and extr emities pink
Appear ance
Pulse r ate
0
<100
≥100
Pulse
Ref lex ir r itabilit y
no r esponse gr imace/f eeble cr y cr y or pull away to stimulation when stimulated when stimulated
Gr imace
Muscle tone
none
some f lexion
f lexed ar ms and legs that r esist extension
Activity
Br eathing
absent
weak, ir r egular , gasping
str ong, lusty cr y
Respir ation