NCM 107 LECTURE

of Mother, Child and

Adolescent
(Well Clients)
PRENATAL VISIT
 OBJECTIVES
After mastering the content of the slides,
students will be able to:
1. Describe the areas of health assessment
commonly included in the pre-natal visit;
2. Compute for the age of gestation and
expected date of confinement;
3. Identify appropriate laboratory
examinations performed to pregnant
client; and
4. Identify teratogens that could possibly
affect the growing fetus.
 PRE NATAL CARE
PRE NATAL CARE GOALS OF PRE NATAL CARE
-defined as monitoring and managing
of patient during pregnancy to  A healthy, prepared mother
prevent complications and promote having minimal discomforts.
healthy outcome for both mother and
 Identification of potential
infant
-Also called ante natal care problems or complications as
early as possible.
 Safe delivery of a healthy infant
 A prepared father or partner
who participates as much or as
little as the couple desires
 Prepared siblings and
grandparents
 TERMS USED
GPTPALM Nulligravida
 Gravida  A woman who has
 Para never been pregnant
 Term Primigravida
 Preterm
 Abortions  A woman pregnant for
 Living the first time
Multigravida
Gravida
 Refers to the number  A woman who has
of times a woman has had two or more
been pregnant,
regardless of the pregnancies
outcome of the
pregnancies.
`
 PARITY
PARA/ PARITY NULLIPARA
 A woman who has never
• Describes the number of delivered a fetus that
times a woman has given reached the age of viability.
birth to a gestationally Primipara
viable fetus (after 24
weeks gestation) whether  A woman who has
infant born alive or dead. completed one pregnancy to
viability
 Has delivered once after 24
weeks’ gestation
Multipara
 Has delivered twice or more
after 24 weeks’ gestation
 TERM BIRTH
TERM BIRTHS
A pregnancy between 37 and 42 weeks
gestation
PRETERM BIRTHS
Delivery after 24 weeks’ gestation but before
37 weeks (full term)
POST TERM
Delivery after 42 weeks gestation
LIVING
Counts the number of living children that the
woman has at that particular time
 COMPONENTS OF PRE NATAL CARE
I. INITIAL INTERVIEW
INITIAL INTERVIEW- establish rapport
 Learning information about the woman’s physical and
psychosocial health
 Obtaining a basis for anticipatory guidance for pregnancy

A. Health History
1. Demographic Data- name, age, address, telephone #, religion
2. Chief Concern- the reason the woman came for consultation

See Chapter 11 ( Pillitteri: Maternal and Child Health Nursing, 8th ed)
 COMPONENTS OF PRE NATAL CARE
3. Family Profile 5. Hx of Family illness
 identify the support  Inherited diseases
person, marital status,
partner’s age, 6. Social Profile
occupation and family  current Nutrition
composition.  elimination
 Sleep
4. History of Past Illness  exercise
 Previous diseases
 Allergies
 Surgical procedure
 COMPONENTS OF PRE NATAL CARE
B. Gynecologic History D. Obstetrical History
 Menarche Previous pregnancy
 Cycle
GPTPALM
 Discomfort
 Past surgery of the
reproductive system
 Sexual history

C. Reproductive Planning
Example: GPTPALM

Mary Ann is G4 P2/ T1 P1 A1 L2 M0 (11120)

G= fourth pregnancy
P= two deliveries
T= one term infant
P= one preterm infant
A= one born before 24 weeks
L= two living children
M= no multiple pregnancy
ESTIMATING EXPECTED DATE OF DELIVERY
RELATED TERMS: Example:
EDC- Estimated Date of COMPUTING EDD
Confinement  LMP- April 10 2020
EDD- Estimated Date of Delivery
EDB- Estimated Date of Birth 04 10 2020
-3 +7 +1____
NAEGELE’S RULE EDD 1 17 2021
To estimate EDD, get the first day January 17, 2021
of the last menstrual period (LMP),
then subtract 3 months, add 7
days, and then add 1 year.
If: Last menstrual period is April 10 to
April 15
 LMP is April 10 (Get the first day)
Estimating Expected Date of Delivery
For LMP that fall between
January to March: Another Method (Unofficial)
 +9 + 7
LMP: Jan 10, 2020
3 months back= October Example
7 days + 10= 17 LMP: January 10, 2020
EDD: October 17, 2020
01 25 2020
+9 +7
EDD 10 32 2020
+1 -31
Nov. 1, 2020
ACTIVITY

• What is the EDD if LMP is

October 15, 2019?

• Compute for the EDD if the

LMP is February 14, 2020.
 Estimates of Age of Gestation ( AOG)
McDonald’s Rule – determines
AOG by measuring the length from the
fundus to the symphysis pubis ( cm) .
 The length in centimetre (fundic
height) correspond to the weeks of
pregnancy.
 A 24 cm fundic height = 24 weeks of
pregnancy

 Typically this is a method applicable

only during the mid pregnancy
growth. Between the 24th to the 31st
weeks of pregnancy.
 Estimates of Age of Gestation
BARTHOLOMEW’S
RULE- estimates AOG
by the relative position
of the uterus in the
abdominal cavity
II. PHYSICAL EXAMINATION
Inspection of the major body system, with
emphasis on the changes that occur during the
pregnancy
A. HEIGHT AND WEIGHT MEASUREMENT-
Serve as a baseline for future comparison.
Get the Pre-pregnancy weight if available to
determine how much weight she already
gain or lost.
 PHYSICAL EXAMINATION
B. VITAL SIGN PULSE RATE
Increase by about 10 beats per
minute due to increase cardiac
BLOOD PRESSURE workload
 No significant change in
BP RESPIRATORY RATE
 Slightly lower in the Increases in depth; no significant
second trimester change
 BP is highest when the  A sudden increase in PR and
woman is sitting, RR rate may suggest bleeding
intermediate in supine during pregnancy
position and lowest in left
lateral position
TEMPERATURE
 A sudden increase in BP Slight elevation of temperature
and weight gain is a sign early in pregnancy due to
of gestational progesterone
hypertension.
Drops to normal after 6 weeks
 PHYSICAL EXAMINATION
C. HEAD TO TOE ASSESSMENT C. Neck
A. Head and scalp  Slight thyroid
enlargement due to
 Hair tends to grow faster during increased BMR
pregnancy D. Nose
 Oily hair is not uncommon  Normal nasal
 Excess hair dryness indicates congestion due to
estrogen stimulation
poor nutrition E. Ears
B. Eyes  Nasal stuffiness results
 Pale conjunctiva indicates in blockage of
anemia eustachian tube which
affects hearing
 Edema of eyelids accompanied
by visual disturbances are signs
of PIH
 PHYSICAL EXAMINATION
F. Mouth and teeth
 Swollen gums due to estrogen
stimulation
 Cracked corners of mouth due to
vitamin deficiency
 Tooth extraction should be
postponed until the postpartum
period
G. Breast
 Enlargement of the breast
 Wider and darker areola
 Prominent veins and
Montgomery’s tubercles
 Colostrum can be expressed
from the nipple
 PHYSICAL EXAMINATION

H. Skin
 Linea nigra
 Mask of pregnancy
 Spider nevi
 Palmar erythema
I. Back
 Exaggerated lumbar curve late
in pregnancy due to the
shifting of the woman’s center
of gravity
 PHYSICAL EXAMINATION
J. Rectum
L. EXTERNAL GENITALIA
 Note for signs of inflammation,
 Hemorrhoids may be present ulceration, lesions, vaginal
discharges
especially in the last months
 Note the presence of herpes
of pregnancy simplex- clustered pinpoint
K. Extremities vesicle on the vulva that is
painful to touch
 Ankle swelling is normal in  Skenes & Bartholins Gland-
the second half of presence of discharge may
pregnancy indicate gonorrhea
 Leg edema  Vaginal muscle wall- presence
of Rectocele ( forward
 Waddling gait due to pouching of the rectum and
relaxation of pelvic joint Cystocele ( forward pouching
 Edema of upper extremities, of the bladder in the anterior
face and hands are danger vaginal wall )
signs
RECTOCELE CYSTOCELE
- forward pouching of the -forward pouching of the
rectum bladder in the anterior
vaginal wall
 PHYSICAL EXAMINATION
N. Vagina
 Walls are pinkish in non
pregnant mother.
 in pregnant woman is
dark blue to purple.
 PHYSICAL EXAMINATION
M. Internal Genitalia- can be
viewed using a speculum

PELVIC EXAMINATION
• Cervix
• Lithotomy position
 Nulligravida- round and small
 Woman with vaginal birth- slit-like
appearance
 With cervical tear from previous birth- star-
like( stellate)
 Presence of erosion – erosion
PAPANICOLAOU SMEAR
- Done during the first prenatal visit
PAPANICOLAO
SMEAR
-A pap smear is taken
from the endocervix
to determine
precancerous or
cancerous condition
of the uterine cervix.
 Estimating Pelvic size
 PELVIC INLET- entrance to the true pelvis
 PELVIC OUTLET- inferior portion, bounded at the
back of the coccyx
 DIAGONAL CONJUGATE- Measurement of the
interior surface of the sacral prominence and the
posterior surface of the symphysis pubis
(10.5-11cm)
 ISCHIAL TUBEROSITY-diameter of the transverse
diameter of the outlet or the distance between
the ischial tuberosities. (11 cm is adequate)
 LEOPOLD’S MANEUVER
Steps in palpating the uterus
through the abdomen in order
to determine the lie and
presentation of the fetus.
 STEP 1
The top of the uterus
(fundus) is felt (palpated) to
establish which end of the
fetus is in the upper part of
the uterus.
BREECH/ CEPHALIC
NOTE:
If either the head or breech
(buttocks) of the fetus are in
the fundus then the fetus is
in vertical lie. Otherwise the
fetus is most likely in
transverse lie.
 STEP 2

Firm pressure is
applied to the sides
of the abdomen to
establish the
location of the spine
and extremities
(small parts).
 STEP 3
Using the thumb and fingers of
one hand the lower abdomen
is grasped just above the pubic
symphysis to establish if the
presenting part is engaged.

NOTE:
If not engaged a movable body
part will be felt. The presenting
part is the part of the fetus that is
felt to be in closest proximity to
the birth canal.
 STEP 4
 Facing the maternal feet, the tips of
the fingers of each hand are used to
apply deep pressure in the direction
of the axis of the pelvic outlet.
NOTE:
If the head presents, one hand is arrested
sooner than the other by a rounded
body (the cephalic prominence) while the
other hand descends deeply into the
pelvis. If the cephalic prominence is on the
same side as the small parts, then the
fetus is in vertex presentation. If the
cephalic prominence is on the same side
as the back , then the head is extended
and the fetus is in face presentation.
LEOPOLD’S MANEUVER
Laboratory Assessment
1. URINALYSIS
 Test for proteinuria, glycosuria, nitrates and pyuria

2. BLOOD SERUM STUDIES

A. Complete Blood Count
 Hgb, Hct & red cell index- determine presence of
anemia
 WBC- determine infection
 Platelet count- estimate clotting ability
B. GENETIC SCREEN FOR COMMON ETHNICAL INHERITED
DISEASE
 Sickle cell trait, G6Pd, Thalassemia & Tay Sachs disease

C. Serologic test for syphilis VDRL or RPR

D. Blood typing ( Rh Factor)- detect ABO incompatibility and

Rh isoimmunization

E. Culture of chlamydia and Gonorrhea

 Once identified, patient is treated with antibiotics

F. Maternal serum fetoprotein (MSAFP) and pregnancy

associated protein
 Done @ 16th-18th week
 Elevated result indicates neural tube & abdominal defect
G. Indirect Coombs test
 determination of the presence of Rh antibodies in an Rh
negative women

H. Serum antibody titers for rubella, hep B ( HBsAG) , Hep C,

varicella

I. HIV Screening
 Done in early pregnancy and retested in the 3rd tri for high risk
women
 ELISA ( enzyme-linked immunosorbent assay)
 Western Blot- confirmatory test

J. HbAIC Test ( Glycated Hemoglobin)

 Done in patient with a history of DM, with babies who were LGA

3. Tuberculosis Screening or the Mantoux Test

 PPD ( Purified protein derivative test
MANTOUX TEST/PPD
4. ULTRASOUND
 Measures the response of sound waves in a solid object.

PURPOSES:
1. Diagnose pregnancy as early as 6 weeks
2. Confirm the presence, location and size of placenta and
amniotic fluid
3. Establishes that the growing fetus has no gross anomalies
4. Established the sex if a penis is revealed
5. Establishes the position and presentation of the fetus
6. Predict gestational age by measuring t e biparietal diameter
(crown to rump measurement.
7. Discover complication of pregnancy. (hydramnios,
oligohydramnios, previa)
8. Detect retained placenta and poor involution.

NOTE: Before examination, the woman is encouraged to drink plenty

of water. This is to facilitate easy visualization of the fetus.
 SIGNS INDICATING POSSIBLE
COMPLICATION OF PREGNANCY
1. Vaginal Bleeding
2. Persistent Vomiting
3. Chills and fever or pain on urination
4. Sudden escape of fluid in the vagina
 HEALTH PROMOTION DURING
PREGNANCY
• BATHING
 Daily bath and showers are recommended
 Extremely hot bath and hot tubs are not advised
because it may cause hyperthermia to the fetus.
 Safety is encouraged as a pregnant woman has
difficulty in maintaining balance
 Tub bath is contraindicated if membranes are
ruptured as this could lead to uterine infection.
 HEALTH PROMOTION DURING
PREGNANCY
• BREAST CARE
 Wear firm supportive bra with wide straps
 Wash breast with clear tap water daily (no soap)

• DENTAL CARE
 Gingival tissue tends to hypertrophy during pregnancy.
Pockets of plaque forms easily which can lead to
periodontal disease.
 Bacteria in the mouth interacts with sugar, and lowers the
pH of the mouth and causes destruction of the enamel of
the teeth. Eating nutritious foods is encourage with proper
dental hygiene.
 HEALTH PROMOTION DURING
PREGNANCY
• PERINEAL HYGIENE
 Good perineal hygiene is needed due to the increase
vaginal discharge.
 Wipe from front to back
 Douching is contraindicated

• CLOTHING
 Wear comfortable maternity clothing.
 Avoid garters, girdles with panty legs, knee high
stockings
 Use moderate to low heel shoes
 HEALTH PROMOTION DURING
PREGNANCY
• SEXUAL ACTIVITY
 Coitus is not contraindicated during pregnancy.
 It does not initiate labor.
 Orgasm does not caused preterm labor
 Coitus does not cause PROM
 WOMEN whose membranes have ruptured or have vaginal
spotting should be advised against coitus.
 Those who have history of preterm birth should consult
their doctors for specific advise.
 Changes n sexual position maybe needed to increase
comfort.
 Caution about non-monogamous sexual partners about STD.
 HEALTH PROMOTION DURING
PREGNANCY
• SLEEP
 Needs enough rest and sleep to build new cells
during pregnancy.
 Position: Left sided Sims position with top legs
forward. (Allows good circulation on the lower
extremities and placing the weight of the fetus on
the bed)
 Avoid resting flat (causes supine hypotension
syndrome)
 Sleep deprivation is associated with fatigue and
growth restriction on the fetus.
 HEALTH PROMOTION DURING
PREGNANCY
• EMPLOYMENT
 Avoid job that involves exposure to toxic substances,
lifting heavy objects and prolong periods of standing
and sitting.

• TRAVEL
 Plan frequent rest periods when travelling( every 2
hours)
 Can drive, as long as they fit comfortably behind the
steering wheel. Seat belts should be used.
 When travelling to a certain place, take note of malaria
or Zika prone areas
 HEALTH PROMOTION DURING
PREGNANCY
• EXERCISE
Chief aim is to strengthen the muscle use in
labor and delivery
1. Pelvic tilt
• Reduces back strain
and strengthen the
abdominal muscles.
 HEALTH PROMOTION DURING
PREGNANCY
2. Abdominal muscle tightening
Increases abdominal muscle tone
While slowly taking in a deep breath, expand
the abdomen.
Then exhale slowly while pulling the abdomen
in until the muscles are completely
contracted.
Relax a few seconds and repeat the exercise
 HEALTH PROMOTION DURING
PREGNANCY
Tailor sit (cross-legged sit)
Stretches the inner thigh muscles
 Adding arm reaches stretches the sides and
upper body and helps relieve upper backache.
Sit cross-legged and stretch
one arm high over head,
then release and exhale and
repeat on other side.
 HEALTH PROMOTION DURING
PREGNANCY
Kegel’s exercise
Strengthen and tighten the perineal muscles
Tighten these muscles and pull them upward
toward the vagina as if trying to stop urination
midstream.
 TERATOGENS
- Any factor , chemical or physical that adversely affects the
fertilized ovum, embryo or fetus

Factors that influence the amount of damage cause by

Teratogen
1. The strength of teratogen
2. The timing
before implantation- unaffected
2nd -8th week – vulnerable to injury
Last trimester- potential to harm
3. The teratogens affinity for specific body tissue
• Lead and mercury – disable the nervous tissue
• Thalidomide- causes limb defects
• Tetracycline- tooth enamel deficiencies and long bone
deformities
MATERNAL INFECTIONS
TORCH
- Test to determine the presence of antibodies against
common infectious teratogenic disease
- Acronym for toxoplasmosis, rubella, cytomegalovirus &
herpes simplex
1. Malaria
- Mother is given chloroquine during the first trimester and
Mefloquine during the 2nd trimester
2. Toxoplasmosis
- Protozoan infection spread through contact with uncooked
meat
3. Rubella ( German Measles)
- Effect to the fetus are: cardiac defect, hearing impairement,
cognitive motor challenge, cataracts, facial palate, restricted
intrauterine fetal growth
PREV: Immunization ( mother should not get pregnant for 3
months)
4. Herpes simplex
- STD spread through intimate contact
Effect:
1st Tri- severe congenital anomalies and miscarriage
2nd & 3rd Tri- Premature birth, intrauterine growth
restriction & neurologic dse.

5. Cytomegalovirus
- May cause severe neurologic challenges, eye
damage, hearing impairment & chronic liver disease
6. SYPHILIS
- A sexually transmitted dse
- If detected early , mother is given antibiotics
for the fetus not to be affected
- If not treated beyond 18th week can cause
hearing impairment, cognitive challenges
and fetal death
- TEST:
- VDRL ( Venerial Dse Research Lab)
- RPR ( Rapid Plasma Reagin)
Teratogenic Maternal Exposure
1. Teratogenic Drugs
a. Finasteride ( for hair growth)
- Fetal deformities
b. Narcotics ( Demerol & Heroine)
- Fetal growth restriction
c. Cocaine
- miscarriage, pre term labor, meconium
staining I IUGR
Herbs
1. Green Tea
- interfere with the absorption of folic acid
2. Alcohol
- Babies may have congenital craniofacial
deformities and fetal alcohol spectrum ( cognitive
impairment)
3. Tobacco
- Low birth weight or SGA
- Risk of still birth and SIDS
Environmental Teratogen
1. Impure Air- fetal growth restriction
2. Metal and chemical hazards
- Lead ingestion may lead to cognitive and
neurologic challenge
3. Radiation
-Exposure before implantation – zygote will die
4. 6th week – nervous system and brain are affected
5. Hyperthermia- detrimental to the growth of the
fetus
6. Maternal stress – affects the nutrient & blood
supply to the fetus
 EINC UPDATES ON ANTEPARTUM
EINC Updates on antepartum
 beneficial outcomes of antenatal steroids in mothers
who are in pre term labor.
 - overall reduction in neonatal death
 - reduction in the incidences of respiratory distress
syndrome and cerebroventricular hemorrhage
 - reduction in sepsis in the first 48 hours of the
newborn’s life. It likewise does not increase the risk of
death, chorioamnionitis or puerperal sepsis in the
mother.
• BETAMETHASONE -is the preferred steroid because it is
associated with less periventricular leukomalacia, a
disorder of the white matter of the brain.
End of slide