NURSING CARE DURING PRENATAL PERIOD 3 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= dune 14-18, 2008 LMP: June 14, 2008 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 47 10 22 2005 (October 22, 2005) 2. LMP : December 16 2004 12 16 2004 03 470 41 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) > Mec Donald's Rule * Fomula) AOG (months)= Fundic height (in om)+ 4 E.g. FH of 24cm = 2444 = 6 months (24 weeks) “For 20 weeks AOG and above: FUNDIC HEIGHT (CM) = AOG (WEEKS) “For below 20 weeks AOG: FH (CM) x8/7 = AOG in weeks > Bartholomew's Rule - estimates AOG by the relative position of the uterus in the abdominal cavity AOG Anatomical Landmark: “Zweeks 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. 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- (ic. 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 LMS: fetal engagement LM4: fetal attitude 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 C. Laboratory tests ‘Urine Heat acetic- ALBUMINURIA Benedict's tests- GLYCOSURIA Urinalysis- UTI Blood CBC (Hgb, Het)- ANEMIA Blood typing VDRL- SYPHILIS 4. Diagnostic Tests Ultrasound > Intermittent ultrasonic waves are transmitted by an altemating current to a transducer, which is applied to the women’s abdomen > : A. Transabdominal B. Transvaginal R ‘ities: 1. Drink 1 1.5 quart of water 2 hours before the procedure ===. (HCG) 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 > tis 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. Eetal Health * Assesses appropriate levels of a. Alpha- fetoprotein (AFP) 1 NTD b. Human chorionic gonadotré . Unconjugated estriol (UE) * Necessary for detection of DOWN SYNDROME (TRISOMY 21), TRISOMY 18, and NEURAL TUBE DEFECT 2. Eetallung maturity * Assesses for: a. Lecithin’ Sphingomyelin (L/S) ratio-surfactant“*By 35 weeks AOG, the normal US ratio= 2:1; decrease risk of acquiring Respiratory Distress Syndrome b. Phosphatidylglycerol (PG)- **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 initabilty 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 quailty 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 Equivocal/ ‘*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 f etal breathing movement 2. f etal movements of body or limbs 3 f etal tone (extension or flexion of extremi 4. ) mniotic fluid volume (visualized as pockets of fluids around the fetus) 5, r eactive 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) ‘Component [Normal score= 2) | Abnormal (seore= 0) Fetal breathing = tevisode of “= 30 seconds of movement 9 rhythmic breathing breathing in 30 lasting 20 seconds. | minutes within 30 minutes Fetal 3 discrete body or | =2 movements in 30 limb movements in| minutes movements of 30 minutes (episodes body or limbs | of active continuous movement considered a8 single movement), Fotal tone 2 1 episode of No movements or extensionofafetal_ | extensionffexion extremity with return to flexion, of opening or closing othand ‘Amniotic fluid | = 2 accelerations of= | 0-1 acceleration n 20 15 beatsimin for 15 | minutes volume ‘seconds in 20 minutes Non stress Test | Single verical pocket | Largest single vertical >2em pocket sem Ascore of 2is as: ned 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. Hypeethyroidi sm 14, Renal disease 16. Nonreactive NST Chotipnici¥al Semel > Invol ves obtaining a small sample of chorionic vill from the developing placenta > For 1" trimester diagnosis of genetic, metabolic, and DNA stu > Can be performed either transabdominally or transcervically > Perfo rmed between 10 and 12 weeks; thus it can not detect neural tube defect > Risk of CVS include: 6. F ailure to obtain tissue 7. R upture of membranes 8. L eakage of amniotic fluid 9. B leeding 10. 1 ntrauterine infection 14 M atemal tissue contamination of the specimen 12. R h alloimmunization13. s pontaneous abortion I. Diagnosis Wellness diagnosis Knowledge Deficit Altered Health Maintenance Nutrition, less than required I, Planning/ Implementation! Evaluation A. Nutrition — most important aspect “Nutritional assessment is based on taking a diet history firs: 1. food preferences! eating habits 2. cultural/reigious 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 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. tron H. Managing Discomforts of Pregnancy G. Clothing Use of abdominal support such as light matemity 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 |. Prenatal visit Start of pregnancy ~ 32 weeks Every month On 32-36 weeks AOG Every 2 weeksitwice a month On 36 weeks AOG Every week until labor pains set in