The Antepartal Period
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The Antepartal Period

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The Antepartal Period The Antepartal Period Presentation Transcript

  • THE ANTEPARTAL PERIOD
    BY:
    Zosi Farah w. Fernandez, RN
  • Anatomy and Physiology
    Uterus
    • Serves as an organ of implantation for the fertilized ovum that becomes the fetus
    • Responsible for expulsion of the fetus during childbirth from the strong muscle contractions as well as menstruation
    • Fundal height
    a. At the level of the sypmphysis at 12-14 weeks
    b. Rises at 1 cm/week until 36 weeks of gestation
    c. At the level of umbilicus at 20 weeks
  • b. Cervix
    • Goodell’s Sign
    • Chadwick’s sign
    c. Vagina
    • Slight acidic pH (4-5) to decrease risk of infections
    • Functions include out passage for menstrual flow from the endometrium of the uterus, the female organ for intercourse, and a passageway for vaginal childbirth
    • During pregnancy the mucosa of the vagina may have a bluish violet color, has increased vascularity, and increase vaginal mucus discharge
    d. External structure
    • External genitals organs, or vulva, include all the structure found externally between the pubis and the perineum
    • Structures include the mons pubis, labia majora, labia minora, prepuce, frenulum, fourchette, clitoris and vestibule
    e. Ovaries
    Photograph of the vulva. 1. Pubic hair (shaved), 2.Clitoral hood, 3. Clitoris, 4. Labia majora, 5. Labia minora (enclosing the Vaginal Opening), 6. Perineum.
  • e. Placenta
    • Chorionic villi form and invade the lining of the uterus where endometrial arteries fill with blood.
    • Earliest function is as an endocrine gland to excrete:
    a. hCG
    b. hPL
    • Metabolic function of placenta:
    a. Respiration
    b. Nutrition
    c. Excretion
    • Fetal blood cells can leak into maternal circulation from occasional breaks in the placenta membrane and the mother may develop antibodies to the fetal blood cells.
    • Interference with the circulation to the placenta, such as maternal vasoconstriction from hypertension or cocaine or decreased maternal blood pressure or decreased maternal cardiac output, impedes the blood supply to the fetus.
  • g. Membrane
    h. Umbilical cord
    • Two arteries
    • One vein
    • Wharton’s jelly
    • Usually located centrally as the placenta develops from the chorionic villi
    Amniotic fluid
    • Functions include fetal lung development, protection of the cord, and allows for normal limb development and development of GI and renal System
    j. Cardiovascular System
    • Vena caval syndrome
    • Blood volume increases 30-50% during pregnancy
    k. Gastrointestinal system
    - Constipation and gastroesophageal reflux
  • l. Urinary System
    • Similar relaxation of the urinary tract places the pregnant client at risk for UTI or pyelonephritis from bacteria ascending from perineum
    m. Endocrine system
    Pancreas
    Thyroid
    Pituitary
    n. Respiratory system
    • Increased BMR requires more oxygen for the pregnant body
    • Tidal volume and minute ventilation increase until the third trimester when the large uterus may impede lung expansion
    • CO2 output increases, resulting in slight respiratory alkalosis
  • o. Hematologic system
    • RBC increased by one-third
    • Plasma volume increase is greater, resulting in physiologic anemia of pregnancy
    • Clotting factors increase in pregnancy, which increase the client’s risk for blood clots
    p. Breast
    q. Skin
    • Increased pigmentation
    • Chloasma
    • Linea nigra
    • Striaegravidarum
  • Chloasma
    Linea nigra
  • Striaegravidarum
  • r. Fetal development
    Fertilization
    Implantation
    Placental development
    Developmental landmarks
    a. Fetal heart tones
    b. Quickening
    5. Infants at genetic risk of abnormalities
    a. African American: sickle cell disease
    b. Jewish ethnicity of Northern European descent: Tay-sachs disease
    c. Mediterranean: Thalassemia
    d. Family history of hereditary condition such as cystiic fibrosis or cleft lip palate
    e. Born to a woman of advanced maternal age
    f. Parents are closely related blood relatives
  • 6. Chromosomal abnormalities
    a. Types of transmission to the fetus:
    1. Autosomal dominant
    2. Autosomal recessive
    3. Sex-linked transmission
    b. Down syndrome
    • Risk increases in women over 35 years old and continues to increases with each year of age
    • Characteristics:
    Low-set ears, large fat pads at the nape of a short neck, protruding tongue, small mouth and high palate, epicanthal folds and slanted eyes, small rounded head with flattened occiput, hypotonic muscle with hypermonility of joints, simian crease across the palm of hand and mental retardation
  • c. Turner’s syndrome
    Characteristics:
    • Usually infertile
    • Small stature
    • Cognitive functions unimpaired
  • d. Klinefelter’s syndrome
    Characteristics:
    * usually infetrille
    * cognitive functions vary from unimpaired to mild mental retardation
  • e. Inborn errors of metabolism
    Phenylketonuria (PKU)
    Tay-sachs disease
    Cystic fibrosis
    Congenital adrenal hyperplasia
    Congenital hypothyroidism
  • Assessment
    Prenatal care
    Assessment of positive pregnancy
  • 2. Naegele’s rule
    • To determine the estimated date of confinement or estimated date of delivery, count back 3 months from the first day of the last menstrual cycle and then add1 year and 7 days
    3. Obstetrical classification
    Grvida
    Para or parity
    G-T-P-A-L
    4. Frequency and elements of maternal and fetal assessment
    Initial visit
    a.1 Intake assessment
    a.2 Lab evaluation
    a.3 Client education
    b. Period specific evaluation in pregnancy
    b.1 Every 4 weeks until 28 weeks AOG
    b.2 5-20 weeks of gestation:
    Maternal alpha-feto protein, begin preterm birth prevention education and review warning signs
    b.3 20-24 weeks of gestation:
    Preterm prevention education
  • b.4 24-28 weeks of gestation:
    1 hour glucose tolerance test, cervical exam, begin education and treatment if diabetic, and review preterm birth prevention and warning signs
    b.5 every 2 weeks from 28 to 36 weeks of gestation
    b.6 28-36 weeks of gestation:
    CBC, blood group antibody screen if Rh negative, give Rh immune globulin; cervical examination, follow up with a dietician if diabetic, breast assessment and education preparation for breastfeeding, review of warning sign, and begin parenting class
    b.7 35-37 weeks of gestation:
    Vaginal and rectal group B beta strep culture
    b.8 weekly visits from 36 weeks of gestation until delivery
    b.9 36-40 weeks of gestation:
    CBC, repeat gonorrhea, chlamydia, RPR,HIV, hepatitis B screen if indicated, educate about sign of labor and begin childbirth preparation
  • Assessment of psychosocial aspect of pregnancy
    Economic status
    Marital status
    Age
    Perceived support
    Self-esteem
    Culture
    Religion and importance of faith beliefs
    Stability of living condition
    Assess mood
    i.1 ambivalence
    i.2 Increased sensitivity and irritability
    i.3 sense of vulnerability
    i.4 fear
  • j. Assess developmental task of pregnancy
    1. Pregnancy validation
    2. Fetal embodiment
    3. Fetal distinction
    4. role transition
  • B. Assessment of High-Risk Pregnancy
    Health history
    Social history
    Problems with pregnancy
    Physical exam
    Inspection
    Auscultation
    Palpitation
    Vital signs
  • Diagnostic Studies
    a. Sterile Speculum Exam
    • Indicated for suspected ruptured membranes
    • Amniotic fluid will turn Nitrazine paper blue because of the alkaline pH
    • Free flow of fluid may be seen coming through the cervix when the clients is asked to cough or perform a valsalva maneuver
    Preprocedure:
    Client is assisted into the lithotomy position
    Gather supplies
  • b. Urinalysis with reagent strips
    • Urine is tested with a reagent strip to test for the presence of components in the urine such as WBC, blood, protein, bilirubin, leukocytes, ketones, glucose, specific gravity, pH, urobilinogen and nitrite.
    Preprocedure
    Instruct the client not to discard urine
    Postprocedure
    Compare the result with the legend on the side of the bottle to determine normal or abnormal findings
    Discard the urine and record the result
    c. 24 hour Urine
    • The clients total urine output for 24 hours is collected and analyzed for amount, specific gravity, pH, presence and amount of protein and creatinine clearance.
    Preprocedure
    Instruct the client not to discard any urine for 24 hours
    Obtain specimen on ice for the duration of the test
    Have the client empty the bladder and record the start time
    Post sign in the bathroom to remind the client, family, and all staff that the test is in progress
  • Postprocedure:
    Send the entire specimen to the lab
    Record the end time
    d. Urinalysis and culture
    • They are useful in determining the presence of a UTI, which during pregnancy can result in preterm labor
    Preprocedure
    Obtain the specimen as ordered
    Lable the specimen and send it to the lab
    e. Laboratory Serum Evaluation
    CBC
    Metabolic panel
    Liver proofile
    D-dimer and fibrinogen
    Kleinhauer-Betke
    C-reactive protein (CRP)
    Beta hCG
    Maternal serum alpha-fetoprotein (AFP or MS-AFP)
    OB panel
    TORCH
  • f. Fetal Fibronectin
    • A protein found in amniotic fluid, the placental tissue itself and following injury to membranes-either mechanical or inflammatory
    • Used to gauge the risk of preterm birth for client hospitalized with PTL
    Preprocedure:
    1. Assist the client in assuming the lithotomy position
    2. Gather the equipments
    g. Oral glucose tolerance test (OGTT or GTT)
    • Blood glucose greater than or equal to 140 indicates an abnormal screen, and the 3 hour GTT is indicated
    • 3-hour GTT: 100 grams of glucose is given to the client to drink in a liquid form in 5 minutes; fasting is now required for 12 hours before the test as well as for 3 hours after, serum glucose levels are evaluated at 1,2, and 3 hours after drinking the glucose solution
    Preprocedure:
    Obtain the glucose solution and arrange for the blood draw on schedule
  • h. Daily Fetal Movement count
    • Advised to do daily or twice daily in high-risk client
    • Counting 10 movements in 1hour is reassuring kick count
    i. Electronic fetal monitoring (EFM)
    j. Ultrasound
    • Ultrasound scanning can be either transvaginally or transabdominally
    • Indication for antepartum care include estimation of fetal age, fetal weight and fetal presentation, placenta position and integrity, or a follow-up of fetal anomalies or well being
  • k. Biophysical Profile (BPP)
  • l. Umbilical artery dopplerVelocimerty
    • Noninvasive test is done via ultrasound, examining the umbilical artery
    • Test is done when placenta/fetal perfusion compromise is suspected
    m. Amniocentesis
    • Amniotic fluid is then removed for the following indicators:
    *genetic screening
    * diagnostic for isoimmunization
    *follow-up after an abnormal ultrasound
    * to evaluate fetal lung maturity
    * to evaluate for subclinical infection
    * or to aspirate amniotic fluid to reduce volume
    Preprocedure
    Written consent discussion must take place between the client and the physician
    Educate the client about the procedure
    Postprocedure
    EFM for minimum of 30 minutes
    Give Rh immune globulin for women who are Rh negative
  • n. Group B Beta Streptococcus (GSBBS) Culture
    • Universal screening at 35-37 weeks of gestation
    • Indicated for clients hospitalized preterm with high-risk pregnancy condition
  • Nursing Diagnosis
    Deficient Knowledge
    Acute pain
    Risk for constipation
    Disturbed body image
    Ineffective coping
    Risk for deficient fluid volume
    Noncompliance
    Anxiety
    Imbalanced nutrition: less than body requirements
  • Normal pregnancy
    40 lunar weeks gestation
    Term pregnancy is from the beginning of the 38th weeks until the completion of 42 weeks.
    Normal concerns of pregnancy
    Nausea and vomiting
    Breast tenderness
    Urinary frequency
    Constipation and hemorrhoids
    Light headedness or dizziness
    Leg cramps
    Fatigue
    Heartburn
    Backaches
    Emotional reactions
    Sexuality and intimacy
  • High Risk Pregnancy Condition
    I. Preterm labor
    • Progressive dilatation or effacement of the cervix with uterine contraction or cervical dilatation greater than or equal to 2 cm or cervical effacement of greater than 80% between 20 and 37 weeks of gestation with intact membranes.
    • Risk factors for PTL:
    • African-American race
    • Young or advanced maternal age
    • Low socioeconomic status
    • History of previous PTB
    • Multiple pregnancy losses or abortion
    • Uterine or cervical anomalies
    • Infection
    • Incompetent cervix
    • Bleeding during pregnancy
    • Multiple pregnancy
    • PROM
    • Smoking or substance abuse
    • Assessment
    a. Careful history
    b. Uterine contractions
    c. Feeling that the baby is balling up and relaxing
    d. Rhythmic backpain, thigh pain and change in vaginal mucus
    • Diagnostic test
    EFM
    Vaginal ultrasound
    Fetal fibronectin
    • Medical-surgical management
    Hospitalization
    Antenatal glucocorticoids for promotion of fetal lung maturity
    Tocolytic therapy
    Prophylactic IV antibiotics
    • Nursing interventions
    Encourage hydration
    Monitor for contractions with EFM and by hand palpation
    Monitor maternal vital signs
    Provide comfort measures and emotional support
    Report the changes to the physician
    Obtain lab specimen as ordered
    Encourage bed rest and side-lying position
    Prepare the client and family for possible diagnostic procedures and tests
    Instruct the client about early clinical manifestation
    Perform kick counts for contraction
    Perform a digital cervical exam
  • II. Incompetent cervix
    • May result in spontaneous abortion or preterm delivery
    • Complications include PTB, PROM and intrauterine infection or chorioamnionitis
    Assessment
    • Effacement and dilatation of the cervix not associated with pain or uterine contraction
    Diagnostic tests
    • Similar to PTL, excluding fetal fibronectin
    Medical-surgical management
    • Cervical cerclage
    Nursing intervention
    • Evaluate for contractions
    • Evaluate cervical changes through a digital rectal exam or vaginal sonogram
    • Assess lab values and clinical picture for infectious process
  • III. Premature Rupture of Membrane
    Complications include risks to the mother and risks to the fetus;
    Risk to the mother include sepsis secondary to chorioaminionitis, postpartum endometritis, placental abruption and death
    Risk to the fetus include umbilical cord prolapse, meconium aspiration, infection or sepsis, skeletal compression deformities, abruption, death, onset of labor/prematurity and possibly cerebral palsy secondary to chrorioamnimitis
    Diagnostic test
    Ultrasound
    BPP
    Serial lab test
    Amniocentesis
  • Medical-surgical management
    Prophhylactic antibiotic
    Antenatal glucocorticoids
    Induction of labor
    Emergency CS
    Close observation for complication
    Nursing intervention
    Medicate as prescribe
    Encourage bed rest
    Encourage hydration
    Monitor maternal vital sign
    Monitor intake and output
    Provide comfort measures and support
    Encourage side-lying position
    Assess for contraction
    Palpate the abdomen and uterus for tenderness
    Ask the client about pain
    Monitor FHR pattern
  • IV. Diabetes in Pregnancy
    • Oral hypoglcemia are contraindicated in pregnancy
    • Maternal complication include increased risk for the mother developing DM later in life if GDM and fetal complications include risk to pregnancy such as macrosomia, stillbirth, organ malformation,pre-eclampsia, and increased chance of operative delivery
    Diagnostic test
    OGTT
    Screen at first prenatal if client has any risk
    Nursing intervention
    Provide the client with an appropriate diet
    Instruct the nature of disease
    Encourage hydration
    Encourage side-lying
    Blood glucose reading
    Administer insulin
    Encourage the client to monitor fetal movement
    Ask about risk factors
  • V. Vaginal bleeding from abruptio placenta
    • Is premature separation of the normally implanted placenta from the uterine wall
    • Associated causes and risk include cocaine, trauma, sudden decompression of the uterine cavity as in PROM, maternal hypertension, cigarette smoking, advanced maternal age and multiparity
    Assessment
    Severe abdominal pain
    Painful hard abdomen
    Fetal distress
    Diagnostic test
    D-dimer and fibrinogen
    Ultrasound
    Nursing intervention
    Monitor vital sign
    Assess fetal status with EFM
    Assess the clients blood type and Rh factors, gestational age, amount of bleeding, painful or painless bleeding, and presence of other medical conditions
  • d. Obtain IV access
    e. Prepare for emergency CS
    f. Administer IV fluids bolus or blood transfusion as ordered
    g. Provide lab specimen
    h. Provide emotional support to the client and family
    Clarify question s to help differentiate between previa and abruption; labor contraction
    j. Avoid performing a vaginal exam
    k. Palpate the abdomen for hard, board like texture
    l. Estimate blood loss
  • VI. Vaginal bleeding from Placenta Previa
    • Placenta is covering or encroaching on the internal os to varying degrees
    Total placenta previa or complete previa
    Partial placenta previa
    Marginal placenta previa
    Low-lying placenta
    • Risk factors include advanced maternal age, mutiparity, African or Asian ethnic background, prior placenta previa, smoking, one or more previous CS delivery and cocaine use.
    Assessment
    • Sudden onset of painless vaginal bleeding
    Nursing intervention
    Prepare the client for an emergency CS
    Place the client on bed rest
    Perform intermittent EFM for onset of labor and fetal well being
    Administer antenatal steroid
    Encourage side-lying
    Provide the client and family education
    Maintain IV access
  • VII. Pregnancy induced hypertension
    • Complex disease process with physiologic effects ranging from hypertension to multiorgan failure
    • May progress into HELLP syndrome with liver involvement and platelet destruction, which life is threatening, or seizure from cerebral edema
    • Risk factors for developing PIH include first preganancy, older than 40 years old, African-american race, DM, twin pregnancy, family history of PIH, antiphospholipids antibody syndrome, and chronic hypertension or renal problem
    Assessment
    • Headache
    • Visual changes
    • Right upper quadrant pain
    • Epigastric pain
    • Nausea and vomiting
  • Diagnostic test
    24 hour urine
    CBC
    Labs
    Ultrasound
    Biophysical profile
    Umbilical artery doppler studies
    Nursing Intervention
    Promote bed rest
    Perform frequent assessments of maternal hemodynamics, lung sounds, urine output, reflexes, symptoms or neurologic irritability and fetal well-being
    Encourage hydration
    Decrease stimulus
    Monitor blood pressure
    Test in urine
    Inspect for edema
    Perform deep tendon reflex
    Palpate for liver tenderness
    Auscultate lung sound
    Measure intake and output
    Administer magnesium sulfate
    Prepare for dexamethasone
    Provide steroid prophylaxis
    Inform that surgical delivery is like
  • VIII. HyperemesisGravidarum
    • Nausea and vomiting are common in pregnancy due to hormones of pregnancy
    • Criteria for the disorder are met with 5% weight loss along with dehydration, electrolyte imbalance, ketosis, and acetanuria
    • Risk factors include young maternal age, obese, nonsmoker, multifetal pregnancy and molar pregnancy
    • Maternal complication include decreased maternal weight gain and electrolyte imbalance, and fetal complications include decreased fetal weight with an increased mortality rate
    Nursing intervention
    Provide small, frequent meals, as tolerated, after an intial period of NPO
    Administer IV hydration
    Monitor intake and output
    Administer antiemetics as ordered
    Provide parenteral nutrition via central line
    Monitor daily weight
  • IX. Heart disease
    • The cardiac disease is classified by the level of functional capacity
    • Most common complication is heart failure
    • The prognosis for the pregnancy and plan of care depend on the degree of cardiac compromise
    Assessment
    Edema
    Poor oxygenation
    Tachycardia, murmurs, chest pain, and irregular pulse
    Nursing Intervention
    Monitor the client for sign of cardiac overload throughout pregnancy
    Evaluate fetal well-being
    Instruct the client as follow: avoid excessive weight gain and emotional stress, report any sign of infection promptly and avoid anemia with adequate nutrition and supplement
    Avoid anemia
    Administer prophylactic antibiotic
    Administer prescribe diuretic
    Treat dysrhythmias and use cardiac glycosides
  • x. Substance Abuse
    • Substance include alcohol, tobacco, marijuana, cocaine, and heroin
    Diagnostic test
    -toxicology screening of urine for drugs
    Nursing intervention
    Support all the clients efforts to decrease substance use
    Monitor the fetal complication
    Screen client for use of substance
    Encourage the client to disclose all substance and amount used
    Monitor for maternal complications
    Promotes a slow withdrawal during pregnancy
  • XI. HIV
    • AIDS is cause by HIV where the classic symptoms surround the severly impaired immune system and devastating opportunistic infections
    • Antiretroviral drugs that control replication of the virus are given to the client
    Assessment
    Flu-like syndrome
    Night sweats
    Chronic diarrhea
    Recurrent headaches
    External fatigue
    Oral hairy leukoplakia
    Diagnostic test
    ELISA
    Western blot
  • Nursing intervention:
    Maintain a nonjudmental attitude
    Offer emotional support and counselling as needed
    Monitor the client for presence of infection
    Implement universal precaution
    Instruct the client about the need for antiretroviral medications
    Prepare the client for the need to formula feed the infant
    Monitor for fetal well-being
    Evaluate for other sexually transmitted diseases and hepatitis B
    Monitor the progress of vital status or disease state with lab test
  • XII. Ectopic Pregnancy
    • Fertilized ovum implants outside the uterus
    • Risk factors include tubal sugery leading to scarring and narrowing, infections in the tubes, pelvic inflammation disease (PID) and IUD contraceptive device
    Assessment
    Vaginal bleeding
    Abdominal pain
    Hypotension
    Diagnostic Test
    B-hCG
    Ultrasound
    Nursing Intervention
    Monitor for sign of hemodynamic instability and shock
    Start an 18 gauge IV, have oxygen available and prepare the client for surgery
    Allow the client and her family
    Administer RhoGAM for appropriate client
  • XIII. Hydatiform Mole
    • Also called gestational trophoblastic disease
    • It can develop into choriocarcinoma or into malignant trophoblastic disease
    Assessment
    Will have positive pregnancy clinical manifestation but abnormal lab values
    Excessive nausea and vomiting
    Ultrasound has classic “snowstorm” pattern
    May have vaginal bleeding or pass parts of the mole
    Diagnostic test
    B-hCG and alpha-fetoprotein
    Ultrasound
    Nursing Intervention
    Assess client with very high B-hCG level
    Assist with the evacuation of the mole
    Assist the evacuation of the mole
    Allow the client and family to grieve
    Administer RhoGAM for appropriate client
    Instruct client on the importance of follow-up in the next year
    Instruct the client on contraception for the next year
  • XIV. Spontaneous Abortion
    • Unplanned pregnancy loss before 20 weeks of gestation
    • Also referred to as a miscarriage
  • Assessment
    Vaginal bleeding
    Passage of clots or tissue
    Uterine cramping
    Declining B-hCG level
    Absence of fetal heart tone or absence of fetal movement
    Diagnostic test
    FHR doppler
    Possibly ultrasound
    Lab values
    B-hCG
    Nursing interventions
    Monitor for maternal blood loss and hemodynamic
    Prepare the client for sugery
    Medicate for pain
    Allow the client and family to grieve
    Administer RhoGAM to appropriate clients
    Advice bed rest
    Evacuate the uterus for incomplete and missed abortion