NURSING CARE DURING PRENATAL PERIOD

I. ASSESSMENT
A. Nursing Health History
1. 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 - 31
February - 14
______________________
60 days / 7 = 8 weeks and 4 days (AOG)

 Mc Donald’s Rule
x 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 (W EEKS)
**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
AOG Anatomical Landmark:
12 weeks Slightly above the symphysis pubis
20 weeks Level of the umbilicus
36 weeks Below the xiphoid process
32 and 40 weeks Same level due to lightening on the 40th week
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 Assessment
1. Leopold’s 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 client’s 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 PREGNANCY

Laboratory tests
Urine
Heat acetic- ALBUMINURIA
Benedict’s tests- GLYCOSURIA
Urinalysis- UTI
Blood
CBC (Hgb, Hct)- ANEMIA
Blood typing VDRL- SYPHILIS
 STAGE PRESUMPTIVE PROBABLE POSITIVE

First Trimester Amenorrhea Chadwick’s signs Ultrasound

Morning sickness Goodell’s sign evidence
Breast changes Hegar’s sign
Fatigue Positive HCG
Urinary frequenc y (pregnancy test)
Enlarging uterus Elevation of BBT

Second Quickening Enlarged abdomen Fetal heart tone

trimester Increased skin Braxton Hicks Fetal movement
pigmentation; Contraction felt by the
(chloasma and linea Ballotement examiner
nigra) Fetal outline on X-ray
Striae gravidarum

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
x 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
x 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 on
1. Fetal Health
x Assesses appropriate levels of:
a. Alpha- fetoprotein (AFP)
b. Human chorionic gonadotropin (HCG)
c. Unconjugated estriol (UE)
x Necessary for detection of DOW N SYNDROME (TRISOMY 21), TRISOMY 18, and
NEURAL TUBE DEFECT
2. Fetal lung maturity
x 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:
x Unusual fetal hyperactivity or lack of movement
x Clear vaginal discharge/ Bleeding
x Uterine contraction or abdominal pain
x Fever or chills
2. Instruct to engage to LIGHT ACTIVITY 24 HOURS after the test
x Rationale: to decrease uterine irritability
3. Increase fluid intake
x 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)
x 3 contractions of good quality lasting 40 seconds or more in 10 minutes without evidence of late
decelerations
x Implies that the fetus can handle the hypoxic stress of uterine contractions
2. Positive (Abnormal result)
x Repetitive late decelerations with more than 50% of the contractions
x Implies that the hypoxic stress of contraction causes a slowing of the FHR
 3. Equivocal/ Suspicious
x 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
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. fetal breathing movement
2. fetal movements of body or limbs
3. 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)
Component Normal (score= 2) Abnormal (score= 0)
Fetal breathing ≥ 1 episode of ≤ 30 seconds of
rhythmic breathing breathing in 30
movement lasting ≥ 30 seconds minutes
within 30 minutes
Fetal ≥ 3 discrete body or ≤ 2 movements in 30
limb movements in minutes
movements of 30 minutes (episodes
body or limbs of active continuous
movement
considered as single
movement)
Fetal tone ≥ 1 episode of No movements or
extension of a fetal extension/flexion
extremity with return
to flexion, or opening
or closing of hand
Amniotic fluid ≥ 2 accelerations of ≥ 0-1 acceleration in 20
15 beats/min for ≥ 15 minutes
volume seconds in 20
minutes
Non stress Test Single vertical pocket Largest single vertical
> 2 cm pocket ≤ 2 cm

 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 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. Hypeethyroidism
14. Renal disease
15. 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 tissue
7. Rupture of membranes

8. Leakage of amniotic fluid

9. Bleeding
10. Intrauterine infection
11. Maternal tissue contamination of the specimen
12. Rh alloimmunization
13. Spontaneous abortion
II. Diagnosis: W ellness diagnosis
Knowledge Deficit
Altered Health Maintenance
Nutrition, 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 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 (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. Hygiene
If membranes rupture or vaginal bleeding is present or during the last month of pregnancy, tub baths
are contraindicated.
D. Travel
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
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. W omen 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
Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal.
Component of
Score of 0 Score of 1 Score of 2
acronym
blue at extremities no cyanosis
Skin blue or pale
body pink body and Appearance
color/Complexion all over
(acrocyanosis) extremities pink
Pulse rate 0 <100 ≥100 Pulse
no response grimace/feeble cry cry or pull away
Reflex irritability Grimace
to stimulation when stimulated when stimulated
flexed arms and
Muscle tone none some flexion legs that resist Activity
extension
weak, irregular,
Breathing absent strong, lusty cry Respiration
gasping