Chapter 12 Nursing Management During Pregnancy Maternity and Pediatric Nursing Chapter 12 Nursing Management During Pregnancy

Risk Factors for Adverse Pregnancy Outcomes See Table 12.1

Preconception Care Immunization status Underlying medical conditions Reproductive health care practices Sexuality and sexual practices Nutrition Lifestyle practices Psychosocial issues Medication and drug use Support system

1st Prenatal Visit Establishment of trusting relationship Focus on education for overall wellness Detection and prevention of potential problems Comprehensive health history, physical examination, and laboratory tests

Comprehensive Health History Reason for seeking care Suspicion of pregnancy Date of last menstrual period Signs and symptoms of pregnancy Urine or blood test for hCG Past medical, surgical, and personal history Woman’s reproductive history: menstrual, obstetric, and gynecologic history

Menstrual History Menstrual cycle Age at menarche Days in cycle Flow characteristics Discomforts Use of contraception

Menstrual History (cont.) Date of last menstrual period (LMP) Calculation of estimated or expected date of birth (EDB) or delivery (EDD) Nagele’s rule Use first day of LNMP 11/21/12 Subtract 3 months 8/21/12 Add 7 days 8/28/12 Add 1 year 8/28/13 = EDB Gestational or birth calculator or wheel Ultrasound

Obstetric History Gravida: a pregnant woman Gravida I (primigravida): first pregnancy Gravida II (secundigravida): second pregnancy, etc. Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more Primipara: one birth after a pregnancy of at least 20 weeks (“primip”) Multipara: two or more pregnancies resulting in viable offspring (“multip”) Nullipara: no viable offspring; para 0

Obstetric History (cont.) Terminology G (gravida): the current pregnancy T (term births): the number of pregnancies ending >37 weeks’ gestation, at term P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks A (abortions): the number of pregnancies ending before 20 weeks or viability L (living children): number of children currently living

Question Is the following statement True or False? A woman who is “para 1” is a woman who has given birth once after 20 weeks' gestation

Answer True Rationale: Primipara (para 1) is a woman who has given birth once after 20 weeks' gestation.

Physical Examination Vital signs Head-to-toe assessment Head and neck Chest Abdomen, including fundal height if appropriate Extremities

Physical Examination (cont.) Pelvic examination Examination of external and internal genitalia Bimanual examination Pelvic shape: gynecoid, android, anthropoid, platypelloid Pelvic measurements: diagonal conjugate, true (obstetric) conjugate, and ischial tuberosity

Laboratory Tests Urinalysis Complete blood count Blood typing Rh factor Rubella titer Hepatitis B surface antigen HIV, VDRL, and RPR testing Cervical smears Ultrasound

Follow-up Visits Visit schedule: Early pregnancy: every 4 to 6 weeks After 30 weeks’ gestation: every 2 to 3 weeks After 36 weeks’ gestation: every 1 to 2 weeks

Follow-up Visits (cont.) Assessments Weight & BP compared to baseline values Urine testing for protein, glucose, ketones, and nitrites Fundal height (see Figure 12.3) Fetal movement Fetal heart rate (see Nursing Procedure 12.1) Teaching: danger signs

Question Is the following statement True or False? A woman who is 24 weeks pregnant would arrange for a follow-up visit every 2 weeks.

Answer False Rationale: A woman who is 24 weeks pregnant would have follow-up visits scheduled every 4 to 6 weeks until she reaches 30 weeks’ gestation.

Assessment of Fetal Well-Being Ultrasonography (see Figure 12.4) Alpha-fetoprotein analysis Marker screening tests Amniocentesis (see Figure 12.5 and Table 12.3) Chorionic villus sampling (CVS) Percutaneous umbilical blood sampling (PUBS) Nonstress test; contraction stress test Biophysical profile Doppler flow studies

1st Trimester Discomforts Urinary frequency or incontinence Fatigue Nausea and vomiting Breast tenderness Constipation Nasal stuffiness, bleeding gums, epistaxis Cravings Leukorrhea

2nd Trimester Discomforts Backache Varicosities of the vulva and legs Hemorrhoids Flatulence with bloating

3rd Trimester Discomforts Return of 1st trimester discomforts Shortness of breath and dyspnea Heartburn and indigestion Dependent edema Braxton Hicks contractions

Nursing Management to Promote Self-Care Personal hygiene Avoidance of saunas and hot tubs Perineal care Dental care Breast care Clothing Exercise (see Table 12.4)

Nursing Management to Promote Self-Care (cont.) Sleep and rest Sexual activity and sexuality Employment (see Teaching Guidelines 12.3) Travel (see Teaching Guidelines 12.4) Immunizations Medications

Question While assessing a woman at 18 weeks’ gestation, which of the following would the nurse report as unusual? Urinary frequency Backache Leukorrhea Flatulence with bloating

Answer A. Urinary frequency Rationale: During the second trimester, urinary frequency typically improves when the uterus becomes an abdominal organ and moves away from the bladder region. Backache and flatulence with bloating are common during the second trimester. Leukorrhea begins in the first trimester and continues throughout pregnancy.

Preparation for Labour, Birth, and Parenthood – Perinatal Education Childbirth education Lamaze (psychoprophylactic) method: focus on breathing and relaxation techniques Bradley (partner-coached childbirth) method: focus on exercises and slow, controlled abdominal breathing HypnoBirthing: aims for a trance-like state in the woman, decreasing need for medications and minimizing her stress during childbirth Birthing From Within: stresses self-discovery as the essence of childbirth preparation.

Preparation for Labour, Birth, and Parenthood – Perinatal Education (cont.) Options for birth setting Hospitals: delivery room, birthing suite Birth centres Home birth Options for care providers Obstetrician Midwife Doula

Preparation for Labour, Birth, and Parenthood – Perinatal Education (cont.) Feeding choices Breastfeeding: advantages and disadvantages Bottle feeding: advantages and disadvantages Teaching Final preparation for labour and birth