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# Handout Prenatal

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• simple yet comprehensive.. useful for my teaching.. thanks.. :)

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• thanks! this was very helpful!

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• Thank you sooo much for this handout! I'm looking for Bartholomew's Rule since I have to report about it tomorrow. Not only that, this hand-out is exactly what I need for my subject since I don't have any notes about this and we will have a quiz about it on Friday. THANK YOU SOO MUCH!

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### Handout Prenatal

1. 1. 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 • 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  Bartholomew’s Rule – estimates AOG by the relative position of the uterus in the abdominal cavity 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 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. 2. 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 STAGE PRESUMPTIVE PROBABLE POSITIVE First Trimester Amenorrhea Morning sickness Breast changes Fatigue Urinary frequency Enlarging uterus Chadwick’s signs Goodell’s sign Hegar’s sign Positive HCG (pregnancy test) Elevation of BBT Ultrasound evidence Second trimester Quickening Increased skin pigmentation; (chloasma and linea nigra) Striae gravidarum Enlarged abdomen Braxton Hicks Contraction Ballotement Fetal heart tone Fetal movement felt by the examiner Fetal outline on X-ray C. Laboratory tests Urine Heat acetic- ALBUMINURIA Benedict’s tests- GLYCOSURIA Urinalysis- UTI Blood CBC (Hgb, Hct)- ANEMIA Blood typing VDRL- SYPHILIS 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 • 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 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 • 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 2. Fetal lung maturity • Assesses for: a. Lecithin/ Sphingomyelin (L/S) ratio-surfactant **By 35 weeks AOG, the normal L/S ratio= 2:1; decrease risk of
3. 3. 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: • Unusual fetal hyperactivity or lack of movement • Clear vaginal discharge/ Bleeding • Uterine contraction or abdominal pain • Fever or chills 2. Instruct to engage to LIGHT ACTIVITY 24 HOURS after the test • Rationale: to decrease uterine irritability 3. Increase fluid intake • 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) • 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 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. 4. 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)  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 Wellness 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 Component Normal (score= 2) Abnormal (score= 0) Fetal breathing movement ≥ 1 episode of rhythmic breathing lasting ≥ 30 seconds within 30 minutes ≤ 30 seconds of breathing in 30 minutes Fetal movements of body or limbs ≥ 3 discrete body or limb movements in 30 minutes (episodes of active continuous movement considered as single movement) ≤ 2 movements in 30 minutes Fetal tone ≥ 1 episode of extension of a fetal extremity with return to flexion, or opening or closing of hand No movements or extension/flexion Amniotic fluid volume ≥ 2 accelerations of ≥ 15 beats/min for ≥ 15 seconds in 20 minutes 0-1 acceleration in 20 minutes Non stress Test Single vertical pocket > 2 cm Largest single vertical pocket ≤ 2 cm
5. 5. 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. 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
6. 6. 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. 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