antepartal care

8/17/2019 Antepartal Care

1/9

URDANETA CITY

UNIVERSITY San Vicente West, Urdaneta City, Pangasinan 2428

[email protected](0!" !#8$#%2 & (0!" !#8$24! 'oc. %%0

SC))* )+ -W-+/1%0% )3* )

THE ANTEPARTAL PERIOD

Assessment

Classification of Pregnancy

A. Gravida number of times pregnant,

regardless of duration, including the present

pregnancy.

!. Primagravida pregnant for the first time

". #$ltigravida pregnant for second or

subsequent time

%. Para number of pregnancies that lasted more

than 20 weeks, regardless of outcome.

!. N$lli&ara a woman who has not given

birth to a baby beyond 20 weeks’ gestation.

". Primi&ara a woman who has given birthto one baby more than 20 weeks’ gestation.

'. #$lti&ara Woman who has had two or more

births at more than 20 weeks’ gestation. . . twins

or triplets count as 1 para.

(. !"#$ !ara subdivided to reflect births that

went to Term, Premature births, A bortions, and

Living children.

)se of GTPAL !regnancy outcomes can be

described with the acronym

GTPAL.

1. G is gravidity, the number of pregnancies,

including the present one.

2. T is term *irt+s, the number born at term

%longer than &' weeks( gestation).

&. P is &reterm *irt+s, the number born before

&' weeks( gestation.

*. A is a*ortions and+or miscarriages, the

number of abortions and+or miscarriages

%included in gravida if before 20 weeks(

gestation included in parity if past 20 weeks(gestation). -ote that a termination of the

pregnancy after 20 weeks is referred to as a

therapeutic termination./

. L is t+e n$m*er of c$rrent living c+ildren.

. N,gele-s r$le for estimating the date of

confinement

1. 3se of N,gele-s r$le requires that the woman

have a regular 245day menstrual cycle.

2. "dd ' days to the first day of the last

menstrual period, subtract & months, and thenadd 1 year to that date alternatively, add ' days

to the date of the last menstrual period and count

forward 6 months.

Determination of Pregnancy

7iagnosis of pregnancy is based on

pregnancy5related physical and hormonal

changes and are classified as presumptive,

probable, or positive.

Presumptive Signs and Symptoms (Subjective)

hese changes may be noticed by the

mother+health care provider but are not

conclusive for pregnancy.

A. "menorrhea %cessation of menstruation)

%. -ausea and vomiting

C. 3rinary frequency

D. 8atigue

E. 9reast changes

. Weight changeG. :kin changes

H. ;aginal changes including leukorrhea

I. ost tests rely on the presence of ?@ in the

blood or urine of the woman.

". Aasy, ine=pensive, but may give false

readings with any handling error, medications,

or detergent residue in laboratory equipment.

'. A=ception is the radioimmunoassay %BC"),

which tests for the beta subunit of ?@ and is

considered to be so accurate as to be diagnostic

for pregnancy.

!repared by$ 7r. hristopher B. 9aDeE

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. hanges in skin pigmentation.

Positive Signs and Symptoms

hese signs emanate from the fetus, are

noted by the health care provider, and are

conclusive for pregnancy.

A. etal +eart*eat$ detected as early as eighth

week with an electronic device after 1Gth week

with a more conventional auscultory device.

%. !alpation of fetal outline.

C. !alpation of fetal movements.

D. 7emonstration of fetal outline by either

ultrasound %after si=th week) or H5ray %after

12th week).

)NDAL HEIGHT

". 8undal height is measured to evaluate thegestational age of the fetus %

9. 7uring the second and third trimesters %weeks

14 to &0), fundal height in centimeters

appro=imately equals fetal age in weeks I 2 cm

. "t 1G weeks, the fundus can be found

appro=imately halfway between the symphysis

pubis and the umbilicus.

7. "t 20 to 22 weeks, the fundus is

appro=imately at the location of the umbilicus.

A. "t &G weeks, the fundus is at the =iphoid

process.

#eas$ring $ndal Heig+t

1. !lace the client in the supine position.

2. !lace the end of the tape measure at the level

of the symphysis pubis.

&. :tretch the tape to the top of the uterine

fundus.

*. -ote and record the measurement.

#ATERNAL RI23 ACTOR2

". German measles 4r$*ella5

1. he risk of maternal and fetal or congenital

infection is related to the trimester of placental

infection.

2. >aternal infection during the first 4 weeks of

gestation carries the highest rate of fetal

infection.

9. 2e/$ally transmitted infections

1. 2y&+ilisa. Jrganism may cross the &lacenta.

b. Cnfection usually leads to spontaneous

abortions.

c. Cnfection increases the incidence of mental

subnormality and physical deformities.

2. Genital +er&es

a. Jrganism may cross the &lacenta.

b. 8etus is contaminated after membranes

rupture or with vaginal delivery.

&. Gonorr+ea

a. 8etus is contaminated at the time of delivery.

b. >aternal infection may result in postpartum

infection of theneonate.

c. Bisks to the neonate include ophthalmia

neonatorum, pneumonia, and sepsis.

C. H$man imm$nodeficiency vir$s 4HI65

1. he virus is transmitted through blood, blood

products, and other bodily fluids, such as urine,

semen, and vaginal secretions.

2. Bepeated e=posure to the virus during

pregnancy through unsafe se=

practices or intravenous drug use can increase

the risk of transmission to the fetus.

&. !erinatal administration of Eidovudine %K7;)

may be recommended to decrease the

transmission of ?C; virus from mother to fetus.

7. 2$*stance a*$se

1. >any substances cross the &lacenta7

therefore, no drugs, including over5the5counter

medications, should be taken unless prescribed by a health care provider.

2. :ubstances commonly abused include

alcohol, cocaine, crack, mariLuana,

amphetamines, barbiturates, and heroin.


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&. :ubstance abuse threatens normal fetal

growth and successful term completion of the

pregnancy.

*. :ubstance abuse places the pregnancy at risk

for fetal growth restriction, abruptio placentae,

and fetal bradycardia.. !hysical signs of drug abuse may include

dilated or contracted pupils, fatigue, track

%needle) marks, skin abscesses, inflamed nasal

mucosa, and inappropriate behavior by the

mother.

G. onsumption of alcohol during pregnancy

may lead to fetal alcohol syndrome %8":) and

can cause Litteriness, physical abnormalities,

congenital anomalies, and growth deficits.

'. :moking can result in low birth weight, a

higher incidence of birth defects, and stillbirths.

A. ;iral hepatitis

8. Adolescent &regnancy

1. 8actors that result in adolescent pregnancy

include the early onset of menarc+e, changing

se=ual behaviors in this age group, problems

with family relationships, poverty, and the lack

of knowledge of reproduction and birth control.

2. he maLor concerns related to adolescent

pregnancy include poor nutritional status,emotional and behavioral difficulties, lack of

support systems, increased risk of stillbirth, low5

birth5weight infants8 fetal mortality,

cephalopelvic disproportion, and increased risk

of maternal complications, such as hypertension,

anemia, prolonged la*or8 and infections.

&. he role of the >idwife in reducing risks and

consequences of adolescent pregnancy is

twofoldMfirst, to encourage early and continued

prenatal care and second, to refer the

adolescent, if necessary, for appropriate

assistance, which can help counter the effects of

a negative socioeconomic environment.

Prenatal Care

A. ime frame

!. irst visit$ may be made as soon as woman

suspects she is pregnant frequently after first

missed period.

". 2$*se9$ent visits$ Avery month until the ' th

or 4th month, every 2 weeks during the 4th

month, and weekly during the 6th month more

frequent visits are scheduled if problems arise.

%. Cond$ct of initial visit

!. A=tensive collection of data about client in all

pertinent areas in order to form basis for

comparison with data collected on subsequent

visits and to screen for any high5risk factors

a. >enstrual history$ menarche, regularity,

frequency and duration of flow, last period

*. Jbstetrical history$ all pregnancies,

complications, outcomes, contraceptive use,se=ual history

c. >edical history$ include past illnesses,

surgeries current use of medications

d. 8amily history+psychosocial data

e. Cnformation about the father5to5be may also

be significant

f. urrent concerns

Interventions

Prenatal Care

A. ime frame!. irst visit$ may be made as soon as woman

suspects she is pregnant frequently after first

missed period.

". 2$*se9$ent visits$ Avery month until the ' th

or 4th month, every 2 weeks during the 4th

month, and weekly during the 6th month more

frequent visits are scheduled if problems arise.

%. onduct of initial visit

!. A=tensive collection of data about client in all

pertinent areas in order to form basis for

comparison with data collected on subsequent

visits and to screen for any high5risk factors

a. >enstrual history$ menarche,

regularity, frequency and duration of

flow, last period

*. Jbstetrical history$ all pregnancies,

complications, outcomes, contraceptive

use, se=ual history

c. >edical history$ include past

illnesses, surgeries current use of

medicationsd. 8amily history+psychosocial data

e. Cnformation about the father5to5be

may also be significant

". omplete physical e=amination, including

internal gynecologic e=am and bimanual e=am

'. #aboratory work, including 9, urinalysis,

!ap test, blood type and Bh, rubella titer, testing

for se=ually transmitted diseases

%:7s), other tests as indicated %e.g., 9 test,

hepatitis viral studies, A@, etc.)

C. onduct of subsequent visits

!. ontinue collection of data, especially weight,

blood pressure, urine screening for glucose and

protein, evaluation of fetal development through

auscultation of fetal heart rate %8?B) and

palpation of fetal outline, measurement of fundal




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height as correlation for appropriate progress of

pregnancy. 8undus palpable above

symphysis at 12 weeks, at the level of umbilicus

at 20 weeks, then appro=imately

1 cm per week until &GN&4 weeks when head

often descends and fundal measurement maydrop somewhat.

". Additional tests

a. ?emoglobin and hematocrit 2GN24 weeks

*. @lucose screen 2*N24 weeks

c. "ntibody screen at 24 weeks

d. 9eginning of 6th month, test for :7s, strep,

other infections

'. Pre&are for any necessary testing.

a. ?ave client void %clean catch).

*. ollect baseline data on vital signs.

c. ollect specimen.

d. >onitor client and fetus after procedure.

e. !rovide support to client.

f. 7ocument as needed.

Nutrition during Pregnancy

A. :eig+t gain

!. ;ariable, but 2 lb usually appropriate for

average woman with single pregnancy.". Woman should have consistent, predictable

pattern of weight gain, with only 2N& lb in first

trimester, then average 12 oE gain every week

in second and third trimesters.

'. @ains mostly reflect maternal tissue in first

half of pregnancy, and fetal tissue in second half

of pregnancy.

%. 2&ecific n$trient needs

!. Calories$ usual addition is &00 kcal+day, but

there will be specific guidelines for those

beginning pregnancy either over5 or underweight

%never less than 1400 kcal+day).

". Protein additional &0 grams+day to ensure

intake of '*N'G grams+day very young pregnant

adolescents and those with multiple pregnancies

will need more protein.

'. Car*o+ydrates$ intake must be sufficient for

energy needs, using fresh fruits and vegetables

as much as possible to derive additional fiber

teach to avoid empty’’ calories.(. ats$ high5energy foods, which are needed to

carry the fat5soluble vitamins.

;. Iron$ needed by mother as well as fetus

reserves usually sufficient for first trimester,

supplementation recommended after this time

iron preparations should be taken with source

of vitamin to promote absorption.

. 6itamins$ both fat5 and water5soluble are

needed in pregnancy essential for tissue growth

and development, as well as regulation of

metabolism. @enerally not synthesiEed by body,

nor stored in large amounts %folic acid special

concern as deficiency may cause fetal anomalies

and bleeding complications).

C. 7ietary supplements$ many health care

providers supplement the pregnant woman’s diet

with an iron fortified multivitamin to ensure

essential levels.

D. 2&ecial concerns

!. Beligious, ethnic, and cultural practices that

influence selection and preparation of foods

". !ica %ingestion of nonedible or non5nutritive

substances)

'. ;egan vegetarians$ no meat products, may

need 912 supplement

(. "dolescence;. Aconomic deprivation


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discomfort, and promote cooperation with the

birth process.

Determination of etal Status and !is"

actors

A. etal diagnostic tests

!. 3sed to$

a. Cdentify or confirm the e=istence of risk

factor%s)

*. ;alidate pregnancy

c. Jbserve progress of pregnancy

d. Cdentify optimum time for induction of labor

if indicated

e. Cdentify genetic abnormalities

". ypes

a. C+orionic villi sam&ling 4C625 earliest test

possible on fetal cells %6N12 weeks) sample

obtained by slender catheter passed through

cervi= to implantation site.

*. )ltraso$nd$ use of sound and returning echo

patterns to identify intrabody structures.3seful early in pregnancy to identify

gestational sac%s) and to assist in pregnancy

dating. #ater uses include assessment of fetal

viability, growth

patterns, anomalies, fluid volume, uterine

anomalies, and adne=al masses.

3sed as an adLunct to amniocentesis

safe for fetus %no ioniEing radiation).

c. Amniocentesis$ location and aspiration of

amniotic fluid for e=amination possible after the

1*th week when sufficient amounts are present.

3sed to identify chromosomal aberrations, se=

of fetus, levels of alpha5fetoprotein and other

chemicals indicative of neural tube defects and

inborn errors of metabolism, gestational age, Bh

factor.

d. ?@ray$ can be used late in pregnancy %after

ossification of fetal bones) to confirm position

and presentation not used in early pregnancy to

avoid possibility of causing damage to fetus and

mother.

e. Al&+a@feto&rotein screening$ >aternalserum screens. "lpha5fetoprotein is glucoprotein

produced by fetal yolk sac, @C tract, and liver.

est done between 1 and 14 weeks’ gestation.

Alevated "8! may be associated with neural

tube defects, renal anomalies. #ow "8! seen

with chromosomal trisomies.

f. L2 ratio$ uses amniotic fluid to ascertain

fetal lung maturity through measurement of

presence and amounts of the lung surfactants

lecithin and sphingomyelin.

"t &N&G weeks, ratio is 2$1, indicative of

mature levels once ratio of 2$1 is achieved,

newborn less likely to develop respiratory

distress syndrome.

!hosphatidylglycerol

%!@) is found in amniotic fluid after & weeks.

Cn conLunction with the #+: ratio, it contributes

to increased reliability of fetal lung maturity

testing. >ay be done in laboratory or by

shake’’ test.

g. etal movement co$nt$ teach mother tocount 2N& times daily, &0NG0 minutes each time,

should feel NG movements per counting time.

>other should notify care giver immediately of

abrupt change or no movement.

+. P)%2 %percutaneous umbilical blood

sampling)$ uses ultrasound to locate umbilical

cord. ord blood aspirated and tested.

3sed in second and third trimesters.

i. %io&+ysical &rofile$ a collection of data on

fetal breathing movements, body movements,

muscle tone, reactive heart rate, and amniotic

fluid volume. " score of 0 to 2 is given in each

category, and the summative number interpreted

by the physician. !rimary suggested use is to

identify fetuses at risk for asphy=ia.

%. Electronic monitoring

!. -onstress test %-:) %see able G5&)

a. "ccelerations in heart rate accompany normal

fetal movement

*. Cn high5risk pregnancies, -: may be used to

assess 8?B on a frequent basis in order toascertain fetal well5being.

c. -oninvasive

". Contraction stress test %:) %see able G5*)


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a. 9ased on principle that healthy fetus can

withstand decreased o=ygen during contraction,

but compromised fetus cannot.

*. ypes

!5 Ni&&le@stim$lated C2T$ massage or rolling

of one or both nipples to stimulateuterine activity and check effect on 8?B.

"5 O/ytocin c+allenge test 4OCT5 infusion

of calibrated dose of C; o=ytocin piggybacked’’

to main C; line controlled by infusion pump

amount infused increased every 1N20 minutes

until three good uterine contractions are

observed within 105minute period.

'5 : never done unless willing to deliver

fetus.

CO#PLICATION2 O PREGNANCB

!regnancy can be complicated by

situations unique to childbearing %e.g., placental bleeding), or by longstanding conditions

predating pregnancy and continuing into the

childbearing process %e.g., age, socioeconomic

status, cardiac problems) for common

discomforts of pregnancy

General #idifery Res&onsi*ilities

A. each danger signals of pregnancy early in

prenatal period so that client is aware of what

needs to be reported to health care provider on

an immediate basis

%. 9e aware that early teaching allows the client

to participate in the identification and reportingof symptoms that can indicate a problem in her

pregnancy.

C. Aarly recognition and reporting of danger

signals usually results in diminishing the risk

and controlling the severity of maternal+fetal

complications.

D. Cnterventions are specific for the individual

risks.

E. Avaluation centers around whether or not the

risk was controlled or eliminated, and how the

maternal+fetal reaction was controlled.

= Pregnancy :arning 2igns

:ome symptoms during pregnancy are

par for the course, but others are cause for alarm.

?ow do you know the differenceO

!. %leeding

9leeding means different things

throughout your pregnancy. Cf you are bleeding

heavily and have severe abdominal pain and

menstrual5like cramps or feel like you are going

to faint during first trimester, it could be a sign

of an ecto&ic &regnancy,/

?eavy bleeding with cramping could

also be a sign of miscarriage in first or early

second trimester. 9y contrast, bleeding with

abdominal pain in the t+ird trimester may

indicate &lacental a*r$&tion, which occurs

when the placenta separates from the uterine

lining.

2. 2evere Na$sea and 6omiting

Ct(s very common to have some nausea when

you(re pregnant. Cf it gets to be severe, that may

be more serious. Cf you can’t eat or drink

anything, you run the risk of becoming

dehydrated,/

&. %a*y1s Activity Level 2ignificantly Declines

"s a general rule, you should have 10 or morekicks in two hours.

*. Contractions Early in t+e T+ird Trimester

ontractions could be a sign of &reterm

la*or. 8alse labor contractions are called

9ra=ton5?icks contractions. hey’re


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unpredictable, non5rhythmic, and do not

increase in intensity. hey will subside in an

hour or with hydration. 9ut regular

contractions are about 10 minutes apart or less

and increase in intensity./

. Bo$r :ater %rea0s

Cf you are not sure if it is urine versus a true

rupture of the membrane, go to the bathroom

and empty your bladder,P she says. PCf the fluid

continues, then you have broken your water.

G. A Persistent 2evere Headac+e8 A*dominal

Pain8 6is$al Dist$r*ances8 and 2elling

D$ring Bo$r T+ird Trimester

hese symptoms could be a sign of

preeclampsia. hat’s a serious condition that

develops during pregnancy and is potentially

fatal. he disorder is marked by high blood

pressure and e=cess protein in your urine that

typically occurs after the 20th week of

pregnancy.

'. 8lu :ymptoms

A=perts say it’s important for pregnant women

to get the flu vaccine since pregnant women are

more likely to get sick and have seriouscomplications from the flu than other women

during flu season.

DI2CO#ORT2 O PREGNANCB

". Na$sea and vomiting

1. Jccurs in the first trimester

2. aused by elevated levels of human chorionic

gonadotropin and changes in carbohydrate

metabolism

&. #idifery Interventionsa. Aating dry crackers before arising

b. "voiding brushing teeth immediately after

arising

c. Aating small, frequent, low5fat meals during

the day

d. 7rinking liquids between meals rather than at

meals

e. "voiding fried foods and spicy foods

f. "cupressure %some types may require a

prescription)g. ?erbal remedies, but only if approved by a

physician or nurse5midwife

%. 2ynco&e

1. 3sually occurs in the first trimester supine

hypotension occurs particularly in the second

and third trimesters

2. >ay be triggered hormonally or caused by theincreased blood volume, anemia, fatigue, sudden

position changes, or lying supine

&. >idwifery Cnterventions

a. :itting with the feet elevated

b. hanging positions slowly

c. hanging the position to the lateral recumbent

to relieve the pressure of the $ter$s on the

inferior vena cava

. )rinary $rgency and fre9$ency

1. 3sually occurs in the first and third trimesters

2. aused by pressure of the $ter$s on the

bladder

&. #idifery Interventions

a. 7rinking adequate amounts of fluid during the

day

b. #imiting fluid intake in the evening

c. ;oiding at regular intervals

d. :leeping side lying at night

e. Wearing perineal pads, if necessary

f. !erforming Qegel e=ercises

D. %reast tenderness

1. an occur from the first through the third

trimesters.

2. aused by increased levels of estrogen and

progesterone.


a. Ancouragement for wearing a supportive bra

b. "voiding the use of soap on the nipples and

areola area to prevent drying

A. Increased vaginal disc+arge

1. an occur from the first through the third

trimesters.

2. aused by hyperplasia of vaginal mucosa and

increased mucus production.


a. !roper cleansing and hygiene

b. Wearing cotton underwear

c. "voiding douchingd. "dvising the client to consult the physician or

nurse5midwife if infection is suspected

8. Nasal st$ffiness

1. Jccurs during the first through third

trimesters


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2. Besults from increased estrogen, which causes

swelling of the nasal tissues and dryness


a. Ancouraging the use of a humidifier

b. "voiding the use of nasal sprays or

antihistamines

@. atig$e

1. Jccurs usually in the first and third trimesters

2. 3sually results from hormonal changes


a. "rranging frequent rest periods throughout the

day.

b. 3sing correct body mechanics

c. Jbtaining regular e=ercise

d. !erforming muscle rela=ation and

strengthening e=ercises for the legs and hip

Loints

e. "voiding eating and drinking foods containing

stimulants throughout the entire pregnancy

?. Heart*$rn

1. Jccurs in the second and the third trimesters.

2. Besults from increased progesterone levels,

decreased gastrointestinal motility, and

esophageal reflu=, and displacement of the

stomach by the enlarging $ter$s&. #idifery Interventions

a. Aating small, frequent meals

b. :itting upright for &0 minutes following a

meal

c. 7rinking milk between meals

d. "voiding fatty and spicy food

e. !erforming tailor5sitting e=ercises

f. aking antacids only if recommended by the

physician or nurse5midwife

C. An0le edema

1. 3sually occurs in the second and the third

trimesters

2. Besults from vasodilation, venous stasis, and

increased venous pressure below the $ter$s

&. >idwifery Cnterventions

a. Alevating the legs at least twice a day

b. :leeping on the side

c. Wearing supportive stockings

d. "voiding sitting or standing in one position

for long periods of time.

R. 6aricose veins

1. 3sually occur in the second and third

trimesters

2. Besult from weakening walls of the veins or

valves and venous congestion


a. Wearing support hose

b. Alevating the feet when sitting

c. #ying with the feet and hips elevated

d. "voiding long periods of standing or sitting

e. >oving about while standing to improvecirculation

f. "voiding leg crossing

g. "voiding constricting articles of clothing

3. Headac+es


trimesters.

2. Besult from changes in blood volume and

vascular tone.


a. hanging position slowly

b. "pplying a cool cloth to the forehead

c. Aating a small snack

d. 3sing acetaminophen %ylenol) only if

prescribed by the physician or nurse5midwife

#. Hemorr+oids


trimesters

2. Besult from increased venous pressure and

constipation&. >idwifery Cnterventions

a. :oaking in a warm sitE bath

b. :itting on a soft pillow

c. Aating high5fiber foods and avoiding

constipation

d. 7rinking sufficient fluids

e. Cncreasing e=ercise, such as walking

f. "pplying ointments, suppositories, or

compresses as prescribed by the physician or

nurse5midwife

>. Consti&ation

1. 3sually occurs in the second and third

trimesters

2. Besults from decreased intestinal motility,

displacement of the intestines, and taking iron

supplements


a. Aating high5fiber foods

b. 7rinking sufficient fluids

c. A=ercising regularly

d. "voiding la=atives or enemas and consulting

with the physician or nurse5midwife about their

use

-. %ac0ac+e




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1. 3sually occurs in the second and third

trimesters

2. aused by an e=aggerated lumbosacral curve

resulting from the enlarged $ter$s

&.>idwifery Cnterventions

a. Ancouraging rest b. 3sing correct body mechanics and improving

posture

c. Wearing low5heeled shoes

d. !erforming pelvic rocking and abdominal

breathing e=ercises

e. :leeping on a firm mattress

J. Leg cram&s


trimesters

2. Besult from an altered calcium5phosphorus

balance and pressure of the $ter$s on nerves or

from fatigue


a. @etting regular e=ercise, especially walking

b. 7orsifle=ing the foot of the affected legc. Cncreasing calcium intake

!. 2+ortness of *reat+ and dys&nea

1. an occur in the second and third trimesters

2. Besults from pressure on the diaphragm


a. "llowing frequent rest periods

b. :leeping with the head elevated or on the side

c. "voiding overe=ertion

d. !erforming tailor5sitting e=ercises



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