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