Before Pregnancy: IDEALLY , a woman planning to have a child should have a medical evaluation before she becomes pregnant. * Place the patient on PNV-Folic acid (Vit B) 400mcg or .4 mg to prevent neural tube defects ( which are birth defects of the baby's brain (anencephaly) or spine (spina bifida). *
Prenatal is helpful:
Managing the remaining weeks of the pregnancy
Planning for possible complications with the birth process
Planning for problems that may occur in the newborn infant
Determine the outcome of pregnancy
Deciding whether to continue the pregnancy
Help promote a live and healthy baby
How do you detect if your are pregnant?
1) urine or blood test
bHCG “Beta Human Chorionic Gonadotropin “
This hormone is released by trophoblastic tissue in the placenta
It may be produced by a choriocarcinoma or some other germ cell tumors, or even other forms of cancer, e.g. lung cancer.
Urine pregnancy test-2wks after ovulation
Serum pregnancy test-6-8 days after ovulation
Qualitative: measures whether bHCG is present (25mlU/ml is +)
Quantitative: measures the exact amount of bHCG produced.
Levels of bHCG
Below bHCG 1200 mlU/ml-
doubles Q 48-72hrs
may take more than 4 days to double.
Failure to double: miscarriage or ECTOPIC
+ Pregnancy test:
Clinical Visits with no high risk:
Q4Wks until 28wks
Q2W from 28-36wks
Every wk from >36wks
As early as 4.5wks
What do you see?
bHCG>1500 see gestational sac.
bHCG>6000 see heart beat
5wks embryo and yolk sac
7wk embryo and yolk sac
Accurate Assessment of gestational age
May be critical information later.
CRL ( crown rump length)- 1-13wks accurate date within +/- 3-5 days of the actual due date.
2 nd tri(14-28wks): biparietal diameter will accurately predict the due date within 7-10 days in most cases .
3 rd tri(>28wks): + or – 2-3wks, femur is most accurate
Naegele rules- EDC=LMP+7d-3m
Fundal height= gest. Age from 18-30wks
First prenatal visit:
take a careful detail history ( looking for factors that might increase the risk for the pregnant woman.)
Check for BP, urine, weight at every visit.
Routine laboratory test ( looking for specific issues that could influence pregnancy )
Expectations and preparation for delivery (childbirth classes, preferred pain mgt, plans for feeding )
A. Obtain detailed family history from all patient/PMH
1. Hx. Of MR, ONTD other anomalies
2. if adopted
B. Formal questionnaire
1. helps with difficult areas
2. Fill out prior to visit
C. Social history
2. Drug and alcohol use
3. other exposures
D. Allergies and medications
Steps you should take to prepare for the examination:
*Ask woman to empty bladder (collect urine for testing). *Prepare to follow a logical order. *Prepare to chart logically immediately after exam (make notes). *Remember to explain everything you are doing.
Each prenatal visit:
Fetal position and shape
The amount of weight you should gain depends on your weight before pregnancy. You should gain:
25-35 pounds: If you were a healthy weight before preg.
28-40 pounds: If you were underweight before pregnancy
15-25 pounds: If you were overweight before pregnancy
Healthy Weight Before Pregnancy:
3-5 pounds during the first trimester
Approximately 1-2 pounds per week in the second trimester
Approximately 1-2 pounds per week in the third trimester
Underweight Before Pregnancy:
5-6 pounds or more in your first trimester; this also can depend on how underweight you were before pregnancy & your health care provider's recommendations
1-2 pounds per week in the second and third trimesters
Overweight Before Pregnancy:
Approximately 1-2 pounds in the first trimester
Approximately 1 pound per week during the last six months
Check the Blood pressure every visit and compare to pre-pregnancy BP.
<20wks with high BP is considered Chronic Hypertension
>20 with high BP no proteinuria= PIH
High BP, proteinuria, and edema= preeclampsia.
Low BP you want to think about endocrine dis.
PH- Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration.
Glucose: Normal = <+ 1. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high.
Protein: Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH.
Leukoesterase: UTI vs trich.
Ketones: Normal = Negative. Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus.
Bleeding/ spotting: sex, cervicitis, chlamydia, polyp, cancer
Leaking: color and quantity- urine or amnio
Quickening: 17-19wks wk
Nausea and vomiting
History of recent illness
Inspection (Look for scars, linea,striae,symmetry)
Assess Fundal Height (cm) approximates weeks of gestation, position, presentation and EFW.
Detect heart beat (120-160bpm) with doppler– usually heard after 9wks or stethoscope @16wks
of the fundus
in cm. equals
MacDonald’s Rule: (cm of fundal height=wks of gestation)
12wks- pubis bone
16wks- between the pubis bone & umbilicus
Full term- xyphoid process
First Maneuver (What is at the fundus)
Examiner faces woman's head
Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse).
Palpate the uterine fundus
2 nd Maneuver
Second Maneuver (Assess Spine and small parts)
Examiner faces woman's head
Palpate with one hand on each side of abdomen
Palpate fetus between two hands
Assess which side is spine and where extremities are located
3 rd Maneuver
Third Maneuver (what is presenting at the pelvis)
Examiner faces woman's feet and Palpate just above symphysis pubis
Palpate fetal presenting part between two hands
The purpose of this maneuver is to determine the pelvic position of the presenting part
Assess for Fetal Descent
4 th Maneuver
Fourth Maneuver (Where is the Cephalic prominence)
Examiner faces woman's head
Apply downward pressure on uterine fundus
Hold presenting part between index finger and thumb
Plans: method of delivery, perinatology, schedule C/S
1. confirm Dates
2. if too early, repeat test
3. approx 70/1000 are abnl low
If low AFP, Estriol, and elevated HCG there is a risk in Downs syn
If unexplained consider level IIUS or Amnio
Low AFP (.8MoM)
Third Trimester lab
26-28wks: hematocrit (if low, mother will receive iron supplementation)
26-28wks: glucose loading test (GLT) - screens for gestational diabetes; if > 140 mg/dL, a glucose tolerance test (GTT) is administered; if fasting glucose > 105 mg/dL, gestational diabetes is suggestive.
>36wks- vaginal/rectal culture for Group B strep.,Gonn, Chlamydia
1. maternal serum testing- triple screen
2. Diagnostic ultrasound (level 2)
3. Fetal echo
1 .Amniocentesis –performed 15-20wks
2. Chorionic villus sampling -@ 9.5-12.5wks, (associated with limb defects in the fetus)
3. fetal tissue sampling
Educated the patient about pregnancy
Educated the patient about danger signs
Educated them of things they should avoid during pregnancy.
Breast swelling and tenderness
Linea nigra from umbilicus to pubis
Nausea and vomiting
Fetal movement 17-19wks
Sciatica (Pain caused by compression of the sciatic nerve)
AVOID DURING PREGNANCY
ALCOHOL AND DRUG USE
EXPOSURE TO TERATOGENS.
EXCESSIVE PHYSICAL WORK
Encourage Good Nutrition Should include: Whole and organic foods; Proteins, fats; micronutrients such as, calcium, iron, magnesium, zinc and vitamins; moderate salt restriction, all in a balanced diet .
What constitutes a high risk pregnancy?
2 Factors that influence high risk pregnancy:
Preexisting medical condition
Age <20 or >35
Previous pregnancy hx
Access to medical care
Size and number of fetus (twins)
Risk factors associated with MOM Factors primarily physiological in origin
Previous hx. Preterm labor
Vaginal bleeding in 2 nd trimester
undx,. UTI pyelonephritis
Maternal low body wt.
Hx. Of multiple D&C or abortions
Previous uterine or cervical sx.
What are lifestyle risk Factors?
Recreational drug use
Cigarette smoking during pregnancy
Low weight gain in pregnancy
Physically demanding work: factory, nursing
Stress: physical, emotional, mental
Lack of family or social support
How do high risk factors affect pregnancy?
Greatest risk is preterm labor
Preterm labor resulting in preterm birth accounts for 75% or preventable perinatal mortality
Preterm birth increases the risk for neonatal health issues:
Long term development delays
Sudden infant death syndrome
Low birth wt.
Reduction in supply of breast milk
Cocaine: placental abruption
Low birth wt
Opiates: neonatal withdrawal, low birth wt, death
Alcohol: fetal ETOH syndrome
Caffeine: assoc. low birth wt. with excessive caffeine ingestion.
Has increase risk:
Postpartum hemorrhage secondary to uterine atony
Increased incidence of twins
Second trimester elective abortion
Offers assessment and screening of fetus
Increase medical attention in the form of increase office visits to monitoring fetal well-being.
ultrasound level one/two-doppler flow, fetal echo
Amniocentesis or CVS
bed rest and hospitalization.
NST and biophysical profiles
NST- noninvasive test of fetal activity the correlates with fetal well-being.
At least 15 beats
Amplitude of 15sec
During a 20min
The score for a nonstress test with a healthy (reactive) result is 2.
During the ultrasound exam four things are checked and given a score of 0 or 2:
the amount of amniotic fluid
movements of the baby's body
the baby's muscle tone
breathing movements made by the baby
Management based on BPP score Score Interpretation MGT 10 Normal Repeat testing 8 Normal Repeat testing 6 Suspect chronic asphyxia If>36wk, deliver or rpt in 4-6hr 4 Suspect chronic asphyxia If >32wk, deliver Or rpt 4-6 0-2 Strongly suspect chronic asphyxia Extend testing 120min, if score<4 deliver @ any gest. age
BPP-designed to identify a compromised fetus during the antepartum period
score of 8 or 10 is considered normal.
A score of 6 is borderline.
A score of 4 or less suggests there may be problems. Your health care provider may recommend an early delivery of the baby.