pregnancy depends on
Pre-pregnancy health of woman
Past pregnancy history
Presence of illness/disease states
Emotional status
Past health history
Gestation
number of weeks since LMP
Abortion (miscarriage)
birth before 20 weeks gestation &/or < 350 gms.
types of Abortion
Elective vs. Therapeutic
Threatened vs. Imminent
Incomplete vs. Complete
Missed
Term
normal duration of pregnancy, 37 to 42 weeks
(average 40 weeks)
Pre-Term (Premature)
20-37 weeks <
Post-Term
>42 weeks
Antepartum
from conception to labor
Intrapartum
labor until birth of placenta
Postpartum
birth of placenta to the return of mother's body (6 weeks)
Gravida
any pregnancy
Nulligravida
never been pregnant
never deliver fetus < 20 weeks
Primigravida = Para
first time pregnancy
delivers a fetus >20 weeks gestation (death or alive)
Multigravida
pregnancy more than one time
Stillborn
- a fetus born dead
> 20 weeks gestation
Preconception Care
Immunization status
Underlying medical conditions
Reproductive health care practices
Sexuality and sexual practices
Nutrition
Lifestyle practices
Psychosocial issues
Medication and drug use
Support system
1st Prenatal Visit
Earlier the better
Establishment of trusting relationship
Focus on education for overall wellness
Detection and prevention of potential problems
Comprehensive health history, physical examination, and laboratory tests
Comprehensive Health History
-Reason for seeking care:
Suspicion of pregnancy
Date of last menstrual period
Signs and symptoms of pregnancy
Urine or blood test for hCG
-Past medical, surgical, and personal history
-Woman's reproductive history: menstrual, obstetric, and gynecologic h
Current Pregnancy & Menstrual History
-Menstrual cycle
Age at menarche
Days in cycle
Flow characteristics
Discomforts
-Use of contraception
Date of last menstrual period (LMP)
-Calculation of estimated or expected date of birth (EDB) or delivery (EDD)
Nagele's rule
Gestational or birth calcul
How to Determine EDC?
-Gestational Wheel
-Nagele's rule
-Quickening - initial fetal movement perceived by mom
-Fundal height assessment
-Auscultation of FHR
-Ultrasound: most accurate in first trimester
Gestational Wheel
1. Place arrow on the FIRST DAY OF LAST normal menses
2. Do not move arrow and look at 40 weeks = EDD
3.Do not move wheel and now look at today's date= number of weeks pregnant today
Nagele's Rule
First day of LMP
Subtract (-)3 months
Add (=) 7 days
eX:LMP: September 3rd (9-3)/(3+7)=6/10
Gravida
a pregnant woman
Gravida I (primigravida)
first pregnancy
Gravida II (secundigravida):
second pregnancy, etc.
Nulligravida
never been pregnant
Para
a woman who has produced one or more viable offspring carrying a pregnancy >= 20 weeks or more
Primipara
one birth after a pregnancy of at least 20 weeks ("primip")
Multipara
two or more pregnancies resulting in viable offspring ("multip")
Nullipara
no viable offspring; para 0
GTPAL
G (gravida): the current pregnancy
T (term births): the number of pregnancies ending >37 weeks'
P (preterm births): the number of preterm pregnancies ending >20 weeks BUT < 37 weeks
A (abortions): the number of pregnancies ending before 20 weeks
L (living
A pregnant woman comes to the clinic for a visit. This is her third pregnancy. She had a miscarriage at 12 weeks and gave birth to a son, now 3 years old, at 32 weeks. Using the GTPAL system, the nurse would document this woman's
A. 31021
B. 30111
C. 21212
D. 20111
Past Pregnancies
Neonatal status of previous pregnancies
Loss of a child
Blood type and Rh Factor
*Prenatal Classes, resources
Father of baby and family involvement
Gynecologic History
Last PAP Smear ( screening test for cervical cancer)
History of Abnormal Paps
Previous infections
Previous gyn surgery
History of infertility
Sexual history
Contraceptive history
Past Medical History
Childhood diseases (varicella)
Hospitalizations
Surgical procedures
Presence of bleeding disorders
Blood transfusions, will you accept bld or bld products
Family Medical History
Medical Issues
Multiple Births
Mental Illness
Congenital diseases or deformities
Causes of death of family members
Personal/Social Information - Red Flags
Age
Race or ethnicity, educational level
Economic level, living conditions
History of abuse (drugs, cigarettes, alcohol) or
physical/emotional
Gravid
Diet
Support systems
Overuse or under use of health care system
Acceptance of pregnancy
Personal preferen
Risk Assessment: AGE
< 16 yrs or > 35:
Preterm birth, preeclampsia, congenital anomalies
Risk Assessment: RACE
African American:
Preterm birth, low-birth weight, infant & maternal death
Risk Assessment:Socioeconomic status
Low:
Preterm birth, low-birth weight
Risk Assessment:Parity
4 pregnancies:
Pregnancy loss, postpartum hemorrhage, c/s
Risk Assessment:
-Underweight: low birth weight births
-Obese: preeclampsia, GDM, C/S, wound infections,endometritis, thromboembolism
-Height< 5 ft.: C/S
-Smoking: spontaneous AB, placenta abruption, placenta previa, low birth weight, preterm birth, SIDS
-ETOH: mental ret
Obstetric Factors
Previous infant > 4,000 g (8 lbs 14 oz):
risk GDM, infant birth injury, c/s, neonatal hypoglycemia (baby is cut off from source of glucose ... the mom)
Previous stillbirth or neonatal death
Maternal psychological distress
RH negative
Rh sensitization
Prev
Risk Assessment:Medical Conditions
-DM:
preeclampsia, SGA or LGA, neonatal hypoglycemia, congential anomalies, fetal or neonatal death
-Hypothyroidism:
SAB , congenital hypothyroidism
-Hyperthyroidism:
Preeclampsia, thyroid storm, neonatal risk for thrytoxicosis
-Cardiac Disease:
Maternal
Preexisting Risk Factors Related to Sexually Transmitted Diseases
slide 26
Rubella - first or second trimester
CMV (Cytomegalovirus)
HSV (Herpes virus type 2)
HIV
Syphilis
GBS infection
Gonorrhea
Chlamydia
Toxoplasmosis
Pelvic shape
gynecoid, android, anthropoid, platypelloid
Pelvic measurements
diagonal conjugate, true (obstetric) conjugate, and ischial tuberosity
diagonal conjugate, true (obstetric) conjugate, and ischial tuberosity
Quickening
-Usually felt between 16-22 weeks
-Generally felt earlier by multiparous mothers-
15-20 weeks
Fundal Height Assessment
McDonald's method to determine gestational age
Measure with hand not tape measure - 20 weeks & less
At symphysis at 12 weeks
Half way between symphysis & umbilicus at 16 weeks
At umbilicus at 20 weeks
Measure with tape measure in centimeters from 22 weeks to 34 weeks.
Fundal height in cm. correlates well with weeks gestation from 22 weeks to 34 weeks.
For example a client at 28 weeks gestation: fundal height should measure about 27-29 cm.
+/- 2cm is considered normal
Fetal Heart Beat
-Doppler device 10-12 weeks (110-160 bpm)
-Fetoscope 18-20 weeks
Ultrasound
Gestational sac seen at 4-5 weeks after LMP
more on slide 35
Crown to rump measurement
measurement used for gestational age from 4d to 12wks
Laboratory Tests
Urinalysis
Complete blood count
ABO and RH typing
Rubella titer
Hepatitis B surface antigen
HIV, VDRL, and RPR testing
PAP smears
Gonorrhea & Chlamydia Culture
Ultrasound
Toxicology Screen
Cystic Fibrocysis
Sickle-Cell Screen
Quad
AFP, UE, HcG & Inhibin A - 12 weeks
for certain birth defects.
Ultrasound (ROA and Sex Determination)
16-20 weeks
Glucose (1hr GTT)
28 weeks
GBS Culture
-Type of bacterial infection that can be found in a pregnant woman's vagina or rectum, if pass for fetus => infection=> preterm
- 36 weeks
Follow-up Visits
Every 4 weeks up to 28 weeks
Every 2 weeks from 29 to 36 weeks
Every week from 37 weeks to birth
Follow-up Visits Assessments
Weight & BP compared to baseline values
Urine testing for protein, glucose, ketones, and nitrites
Fundal height
Quickening/fetal movement
Fetal heart rate
Couvade
-when mom is sick, dad gets sick; or following their cultural roles
-Pregnancy symptoms
-Following through on cultural roles
Sibling Adaptation < 2 yrs
Unaware of maternal changes
Normal for expression of jealousy, resentment, anger
Sibling Adaptation 3 - 12 yrs
Aware of maternal changes
"look, feel, listen"
Questions!!
Cultural Considerations
-Aware and sensitive to cultural differences
-Not all cultures see pregnancy as a medical condition
Cultural Responses to Pregnancy
Use official translator - preferable a female
Nodding does not mean understands
Ask to explain back
Hispanic - small talk first - helps to establish a rapport - taking a interest in the clients personal everyday life
Eye contact - our culture denotes hone
Presumptive Indicators
1.Amennorhea
2.Nausea & vomiting
3.Fatigue
4.Urinary frequency
5.Breast & skin changes
6.Cervical color changes (Chadwick's sign)
slide 49 for explaination
Chadwick's sign
is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow.
Probable Indicators
1.Abdominal Enlargement
2.Cervical softening (Goodell's sign)
3.Softening of lower uterine segment (Hegar's sign)
slide 50
Goodell's sign
.Cervical softening
Hegar's sign
Softening of lower uterine segment
Probable Indicators 2
1.Ballottement
2.Braxton Hicks Uterine Contractions
3.Palpation of fetal outline
4. Pregnancy tests
Slide 51
Uterine fibroids
noncancerous (benign) tumors that develop in the womb (uterus), a female reproductive organ
Braxton Hicks Uterine Contractions
false" labor pains"
probable sign for pregnancy
Positive Indications
1.Auscultation of FHTs
-- Doppler ultrasound
2.Fetal movements felt by examiner
3.Visualization of embryo or fetus
First Trimester
1.Nausea & Vomiting
2.Urinary Frequency
3. Increased Vaginal Secretions (Leukorrhea)
4.Breast Tenderness
5.Fatigue
6.Nasal Stuffiness & Epistaxis
7.Ptyalism (excessive saliva)
page 54-62
Second & Third Trimester
1.Heartburn (Pyrosis)
2.Varicose Veins
3.Constipation
4.GI Track problems
5.Hemorrhoids
6.Backache
7.Changes of Skin and Hair
8.Leg Cramps
9.Carpal Tunnel Syndrome
Nausea & Vomiting of Pregnancy (NVP)
Causes: Hormone
Mild/Mod NVP: begins 4-6 weeks and peaks by 3rd month
Severe NVP: Hyperemesis gravidarum, results in dehydration, electrolyte imbalance, weight loss
Care for NVP
1.Frequent meals-high in carbs & low in fats
2.Small amount of dry carbohydrate before rising in am ( toast, cracker)
3.Avoid brushing teeth within 2 hrs after meals
Encourage rest and relaxation
Urinary Frequency
Causes:
Pressure of growing uterus on bladder
Hormonal effects causing dilation in urinary collection system
Care:
1.Reassure bladder function will return after delivery
2.Teach pelvic floor exercises (Kegel's)
Reduce caffeinated beverages
3.Use of unscen
Increased Vaginal Secretions
- Leukorrhea
-Causes:
Increased epithelial cells and cervical mucous
Hormone stimulation
No other signs of infection- burning, itching or odor
Care:
1.Keep vaginal area clean
2.Avoid douching
Use unscented panty liners
Wear cotton underwear
Instruct patie
Breast Tenderness
Causes:
Hormone influence- increased estrogen/progesterone
Considered a "presumptive" sign of pregnancy
Care:
1.Good fitting/supportive bra
2.Reduction of caffeine intake
Fatigue
Causes: Progesterone
Care:
1.Encourage 8-12 hours of sleep
2.Napping or rest during the day
3.Involve family members by helping out at home
4.Reinforce adequate nutritional intake
Nasal Stuffiness & Epistaxis
Nose: May be edematous
Epistaxis - bloody nose
Rhinitis - stuffiness
Cause:
Elevated estrogen levels
Relief:
Use humidified air
Ptyalism
Rare discomfort of pregnancy with bitter excessive saliva production
Relief:
1.use astringent mouthwashes
2.Chewing gum
3.Sucking on hard candy
4.Limit starch intake
Heartburn (Pyrosis)
1.Avoid fatty foods and lying down too fast
2.Drink 8-10 glasses of water/day
3.Small frequent meals
4.Aluminum hydroxide & magnesium hydroxide (Maalox)
Varicose Veins
Causes:
-Weakening veins often with valve incompetence
-Weight of enlarging uterus causes proximal obstruction - stagnation of blood
-Occurrence increased by family history, advanced age, obesity, and large fetuses
Care:
1.Elevate legs x30 min twice per d
Constipation
cause : progesteron, Iron, uterus weight, alteration in diet or exercise
Care:
1.Dietary intake of roughage - fiber
2.Increase H20 to 6-8 glasses per day
3.Encourage walking, swimming or cycling
Abdomen
1.Diastasis of the rectus muscle
2.Progressive enlargement
3.Ballottement
4.Heartburn
5.Constipation
6.Hemorrhoids
Hemorrhoids
Cause: Varicosities of the rectum,Prolonged sitting or standing,Pushing during 2nd stage of labor, Constipation
Symptoms:
Burning, itching, pain or bleeding
Care:
1. Prevent constipation
2. digital pressure
3.Topical creams or suppositories
4.Witch hazel
Backache
Spine - Lumbar spinal curve may be accentuated
Care:
1.Local moist heat*
2.Warm tub baths
3.Low healed shoes
4.Maternity girdle
5.Pelvic tilt & rocking exercises 10 x per day
6.Proper body mechanics
Pigmentation Changes
Linea nigra
Chloasma/Melasma - pregnancy mask
Darkening of the areolar
Vascular spider nevi
Decreased hair growth
Hyperactive sweat and sebaceous glands
Striae Gravidarum
Stretch Marks
Leg Cramps
Causes:
Fatigue in extremities
Imbalance between calcium and phosphorus
Decreased circulation in extremities
Care:
Flexing foot forward
Massage of calf
Attempt ambulation
Reduce excessive use of phosphates (sodas, processed foods)
Carpal Tunnel Syndrome
Causes:
Compression of median nerve at wrist
Occurs in pregnancy when edema as well as traction on the nerve result in compression
Often worsens in the 3rd trimester
Preexisting CTS worsens in pregnancy
Care:
1.Gentle ROM qid
3.Use of soft wrist splint
4.