Antepartum Nursing Assessment Ch. 15 Kathleen Hughes RN WHNP

Antepartum Nursing Assessment Ch. 15 Kathleen Hughes RN WHNP
Abdominal Assessment Prenatal care (also known as antenatal care) refers to the regular medical and nursing care recommended for women during pregnancy. Prenatal care is a type of preventative care with the goal of providing regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy while promoting healthy lifestyles that benefit both mother and child

Spans 9 months Three Trimesters: First: weeks 1-13 Second: weeks 14-26
Pregnancy Spans 9 months Three Trimesters: First: weeks 1-13 Second: weeks 14-26 Third: weeks 27-40 Vital signs Normal findings Temperature 36.2–37.6°C (97–99.6°F) Pulse 60–90 beats/min Respirations 12–22 breaths/min Blood pressure less than or equal to 135/85 mm Hg Alterations Elevated temperature  infection Increased pulse rate  anxiety, cardiac disorders Marked tachypnea or abnormal patterns  respiratory disease Greater than 140/90 mm Hg or increase of 30 mm systolic and 15 mm diastolic  preeclampsia

Components of Prenatal Care
Early and continuous risk assessment Health promotion Teaching Danger Signs in Pregnancy Medical and psychosocial interventions and follow-up US Dept of Health & Human Services, 1989 Routine assessment for normal progression of pregnancy Prevention and screening for risk factors Identification of high risk situations or complications of pregnancy Provide education, support, advice for the mother and family Provide an on-going screening program to assure optimal growth and development Prevent, detect and manage factors, which pose potential harm to mother and/or fetus Education

Initial Patient History
Assessment of current and past pregnancies Gynecologic history Current and past medical history Family medical history Genetic history Religious, cultural, and occupational history History Stuff Everything in her history is important. Need to know your patient’s obstetrical history and her estimated due date. OB history helps identify any risk factors from previous pregnancies and should include a thorough family history of inherited conditions or unexpected fetal outcomes. Look for prior history of preterm labor or premature rupture of membranes, bleeding disorders, hypertensive disorders, endocrine disorders C/S or other uterine surgery, and recurrent spontaneous losses. Histc History of medical problems establishes her level of risk for complications during pregnancy

Father’s History Family history of genetic conditions Age
Significant health problems Previous or present alcohol intake Drug and tobacco use Blood type and Rh factor Occupation Educational level Methods by which he learns best Attitude toward the pregnancy

Prenatal Risk-Factor Screening
Any findings known to have negative effect on pregnancy outcomes Woman or child Social or personal Preexisting medical disorders Obstetric considerations The goal of risk assessment is to identify women and fetuses at risk for developing antepartum, intra- partum, postpartum, or neonatal complications Promote risk-appropriate care Enhancing perinatal outcome. Demographic factors, such as maternal age and education, have been linked to pregnancy outcomes. Optimal childbearing age is considered to be between 20 and 30 years of age Increased risk of perinatal morbidity after age 35 Children born to mothers younger than 19 or older than 35 years of age have an increased risk of prematurity, congenital anomalies, and risks from other complications of pregnancy Maternal-family reproductive health history (eg, preeclampsia, hypertension, preterm birth) may be particularly significant. Chronic conditions (ie, diabetes, hypertension, or cardiac disease) are known to be affected by the additional physiologic stress of pregnancy.

Obstetrical History Primip – pregnant for the first time
Multip – pregnant for at least the second time Grand multip – pregnant 5 or more times G/P – pregnancies and births Gravida/Para GTPAL Gravida – number of pregnancies Term – delivery after 37.6 (38) weeks Preterm – delivery before the completion of 37 weeks Abortions – elective or spontaneous before 20 weeks or 500 grams Living – number of children currently living The terms gravida and para describe pregnancies, not number of fetuses. Gravida: a pregnant woman. Anyone who is pregnant is said to have a gravid uterus. Cc Count the number of times a patient has been pregnant. If a patient has never been pregnant she is a gravida 0. If she has had 2 living children and 1 miscarriage and is not currently pregnant, she is a gravida 3. If however, this same patient is pregnant, she is a gravida 4. You must count the current pregnancy in the gravidity. Gravida I (primigravida): first pregnancy Gravida II (secundigravida): second pregnancy, etc. Gravida – number of pregnancies Term – delivery after 37.6 (38) weeks Preterm – delivery before the completion of 37 weeks Abortions – elective or spontaneous before 20 weeks or 500 grams Living – number of children currently living Parity – giving birth to a fetus over 500 om, typically greater than 20 weeks gestation. It doesn’t matter in regards?to the definition whether the fetus was bom dead or alive. Keep in mind this identifies the number of births (as a single experience). The number of babies delivered in a birth is not a consideration. You may also think of it as the number of times in which a gravid uterus is completely emptied of the products of conception. {< In other words, twins delivered from a single pregnancy is considered as one parous experience. Primapara: one birth after a pregnancy of at least 20 weeks (“primip”) Multipara: two or more pregnancies resulting in viable offspring (“multip”)

Estimated Date of Birth
What Is Nagele's Rule? April - 3 months + 7 days + 1 = January 21, Based on a regular 28-day cycles Nagele's Rule -- was devised in 1838 by Franz Carl Naegele and has been used by obstetricians around the world for more than 150 years. Nagele's Rule is based on the belief that human gestation is 10 lunar cycles (nine months plus seven days), not on empirical data. Understand her menstrual history When was the first day of her last normal menstrual period (LNMP)? If her periods are usually 7 days long with moderate bleeding and she tells you her LMP was 4-5 days of light to spotty bleeding, This is not normal for her. Ask about her previous menstrual ) – if there were 7 days of moderate bleeding you would use the first day of this menstrual episode to calculate the EDB. Nagele’s rule: Subtract 3 months Add 7 days to 1st day of last menstrual period Use actual # of days in month when crossing over to another month Nagele’s rule assumes a 28-day cycle and pregnancy occurred on 14th day. Adjustment is in order for varying cycles. A “wheel” can also be used to calculate the above findings.

Physical Exam Reproductive System
Abdomen Breasts External genitalia Speculum & Bimanual exam Clinical pelvimetry Mobility of coccyx Assess for pregnancy changes Striae/linea nigra Surgical scar(s) Landmarks of symphysis pubis & umbilicus Measurement of fundal height ( after 20 weeks) Breasts Encourage SBE Evaluate nipples for breastfeeding External genitalia Speculum & Bimanual exam Bimanual exam 1st trimester May result in bleeding from the cervix and cause a more sensitive response to speculum insertion pregnancy is advanced, the symphysis may be painful from separation Vagina, cervix, uterine size Identify any of the “signs” (Goodell, Chadwick, Hegar) Adnexae Clinical pelvimetry Mobility of coccyx Anus and rectum

Uterine Assessment Physical assessment Fundal height McDonald’s method
Centimeters correlate with weeks of gestation Measurements may yield other information

Leopold’s Maneuvers Fetal lie longitudinal or transverse?
What is in fundus? Buttocks or head? Where is fetal back? Where are small parts or extremities? What is in inlet? Confirm findings in fundus? Presenting part engaged, floating, or dipping into inlet? Four-part process Determine the position of the baby in utero Determine the expected presentation during labor and delivery What part is in the fundus? Facing the mother, palpate the fundus with both hands Assess for shape, size, consistency and mobility Fetal head: firm, hard, and round Moves independently of the rest Detectable by ballotement Buttocks/breech: softer and has bony prominences Moves with the rest of the form Determine position of the back. Still facing the mother, place both palms on the abdomen Hold R hand still and with deep but gentle pressure, use L hand to feel for the firm, smooth back Repeat using opposite hands Once you’ve located the back, confirm your findings by palpating the fetal extremities on the opposite side (“lumpy”) Determine what part is lying above the inlet. Gently grasp just above symphisis pubis with the thumb and fingers of the R hand Confirm presenting part (opposite of what’s in the fundus) Head will feel firm Buttocks will feel softer and irregular If it’s not engaged, it may be gently pushed back and forth Proceed to the 4th step if it’s not engaged… Flexed/Deflexed/Extended? Turn to face the woman’s feet Move fingers of both hands gently down the sides of the abdomen towards the pubis Palpate for the cephalic prominence (vertex) Prominence on the same side as the small parts suggests that the head is flexed (optimum) Prominence on the same side as the back suggests that the head is extended

Fetal Assessment McDonald’s Method
McDonald technique and is used after 20 weeks of gestation 3nor after the fundus exceeds the level of the umbilicus. Fundal height relates to gestational weeks between 20 and 35 wks Fundal height according to McDonald’s method is performed to evaluate fetal growth and gestation. The fundal height measurement in centimeters roughly equals the gestational age in weeks, i.e., 29 cm = 29 weeks. Fundal height is influenced by fetal position and amount of amniotic fluid volume. It is expected the fundal height will increase progressively and be approximately equal to the number of weeks gestation. Discrepancies of less than 2 cm should be followed up at the next visit and appropriate interventions made if the discrepancy continues. Referral for UltraSound should be made if the discrepancy exceeds 2 cm. After 36 wks it is no longer reliable because fetal descent begins.

Assessment of Fetal Development
Quickening Fetal heartbeat Ultrasound First trimester transabdominal ultrasound Detect gestational sac at 4–5 weeks after LMP Biparietal diameter predicts EDB within 7–10 days Quickening Fetal movements felt by the mother Experienced between 16 and 22 weeks’ gestation Felt around 20 weeks for a nulliparous woman and as early as 16 weeks for a multiparous patient. Feeling butterfly movements, gas, flicking sensations, or bubbles Fetal Heartbeat ultrasonic Doppler device Ultrasound Ultrasound should be ordered or completed at the initial prenatal visit if the EDB is unknown. Is more accurate in dating the pregnancy the earlier it is completed. BPD predicts (transverse measurement of the fetal head) EDB within 7 to 10 days.

Fetal Heart Rate May detect fetal heartbeat about 10 to 12 weeks’ gestation with a doppler. If you do not hear a FHT at 10 weeks, bring her back in 2 weeks and check it again. If you are still unsuccessful at 12 weeks, you need to order an ultrasound to check for viability and dates. Sometimes your unable to auscultate between 10 and 12 weeks, because there may be a discrepancy of EDB, twins, or a missed abortion. With twins or the obese woman, it may be later before the fetal heartbeat can be detected. After the fetus is palpable. The best place to hear the heart rate is over the back. Expect FHT’s to decrease in rate as the pregnancy advances but still should be between

Abdominal Assessment in Pregnancy
To Recap

Assessment of Pelvic Adequacy
Pelvic inlet Diagonal and obstetric conjugates Conjugata vera Pelvic cavity (midpelvis) Sacrosciatic notch Pelvic outlet The examiner assesses the pelvis vaginally to determine whether the size and shape are adequate for a vaginal birth.

Screening Tests Initial prenatal visit Throughout Pregnancy
Pap smear Complete blood count (CBC), HIV screening Rubella titer ABO and Rh typing Urine culture Hepatitis B and sexually transmitted infection (STI) screening Throughout Pregnancy Genetic screening Throughout pregnancy Gestational diabetes mellitus (GDM) Hemoglobin (Hgb) and hematocrit (Hct) Group B streptococcus (GBS) Hemoglobin electrophoresis Varicella immunity Purified protein derivative of tuberculin (PPD) Genetic screening Cystic fibrosis (CF) Neural tube defects Down syndrome Trisomy 18 Quadruple screen First trimester ultrasound Provide parents with factual information

Danger signs See Table 15-2 DANGER SIGNS IN PREGNANCY, p. 337
Discussed at initial prenatal visit Reviewed each subsequent visit Printed information on Danger sign  possible cause Sudden gush of fluid from vagina Vaginal bleeding Abdominal pain Temperature above 38.3 °C (101°F) Dizziness, blurring of vision, double vision, spots before eyes Persistent nausea and vomiting Sever headache Edema of hands or face seizures or Epigastric pain Dysuria Absent or decreased fetal movement Danger sign  possible cause Sudden gush of fluid from vagina  premature rupture of membranes (PROM) Vaginal bleeding  abruptio placentae, placenta previa, lesions of cervix or vagina, bloody show, cervical or vaginal infection, irritation of cervix from intercourse Abdominal pain  premature labor, abruptio placentae Temperature above 38.3 °C (101°F)  infection Dizziness, blurring of vision, double vision, spots before eyes  hypertension, preeclampsia Persistent nausea and vomiting  hyperemesis gravidarum Sever headache  hypertension, preeclampsia Edema of hands or face  preeclampsia Seizures or convulsions  preeclampsia, eclampsia Epigastric pain  preeclampsia, ischemia in major abdominal vessel DysuriaUTI Absent or decreased fetal movement  maternal medication, obesity, fetal death, fetal distress

Signs of Preterm Labor See Table 15-3 SIGNS OF PRETERM LABOR, p. 337
Painful menstrual-like cramps Dull low backache Suprapubic pain or pressure Pelvic pressure or heaviness Change in character or amount of vaginal discharge (bloody, thinner, thicker) Diarrhea Uterine contractions felt every 10 minutes for 1 hour Leaking of water from vagina Painful menstrual-like cramps Dull low backache Suprapubic pain or pressure Pelvic pressure or heaviness Change in character or amount of vaginal discharge (bloody, thinner, thicker) Diarrhea Uterine contractions felt every 10 minutes for 1 hour Leaking of water from vagina

Signs of Psychologic Problems
Increasing anxiety Depression or feelings of sadness Inability to establish communication Inappropriate responses or actions Denial of pregnancy Inability to cope with stress Intense preoccupation with sex of baby Failure to acknowledge quickening Failure to plan and prepare for baby Indications of substance abuse The perinatal nurse plays an important role in the woman’s psychosocial adaptation. Each woman is unique. She brings experiences, relationships, and realities as she perceives them. Unique experiential history that makes her who she is. This identity of self that forms the foundation for her development of the maternal self and adaptation to the maternal role. Nurse needs to establish an atmosphere in li the woman can freely ask questions and engage in discussions about things that concern her. Psychosocial assessment is an ongoing process, assessment is made at every visit.

Follow up Visits Visit schedule: F/U Assessments
Every 4 weeks up to 28 weeks Every 2 weeks from 29 to 36 weeks Every week from 37 weeks to birth F/U Assessments Weight & BP compared to baseline values Urine testing for protein, glucose, ketones, and nitrites Fundal height Quickening/fetal movement Fetal heart rate Subsequent visits Interval history Physical exam VS, weight Urine dipstick for protein, glucose, ketones Fundal height, FHR at every visit Fetal heart rate bpm Ultrasound (18-20 wks dating and anatomical survey) Leopold’s maneuvers (afer 32 weeks)

Begin assessing developing readiness to take on responsibilities of parenthood See Table 15-4,p. 338
Areas assessed Perception of complexities of mothering Attachment Acceptance of child by significant others Ensures physical well-being Family/patient decisions reflect concern for health of mother and baby Begin assessing developing readiness to take on responsibilities of parenthood See Table 15-4 GUIDE TO PRENATAL ASSESSMENT OF PARENTING, p. 338 Areas assessed Perception of complexities of mothering Desires for baby itself Expresses concern about impact of mothering role on other roles Gives up routine habits because “not good for baby” Attachment Strong feelings regarding sex of baby Interested in data regarding fetus Fantasies about baby Acceptance of child by significant others Acknowledges acceptance by significant other of the new responsibility inherent in child Concrete demonstration of acceptance of pregnancy/baby by significant others Ensures physical well-being Family/patient decisions reflect concern for health of mother and baby Depression during and after pregnancy common Challenges can be overwhelming Infants of depressed women at increased risk Delayed cognitive, neurologic, psychologic and motor development

Father Assess support system if not part of family structure
Provide anticipatory guidance Assess intended degree of participation Support decisions Assessing and fostering progress in the father’s journey to becoming a parent has significant long-term benefits for the man, his partner, and their child (Condon, 2006).

Cultural Considerations
Cultural assessment: Adapt to client needs Know the cultural features of every diverse group Assist with their healthcare needs Special, transitional event in all cultures Beliefs Prescriptive Describe expected behaviors Restrictive Stated negatively and limit behaviors Taboo Specific supernatural consequences Avoid taking pictures during pregnancy to prevent stillbirths. Purchase of infant clothing or supplies can result in a stillbirth. Be sensitive to religious, spiritual, cultural and socioeconomic factors that may influence response to pregnancy Some Hispanic women “do not believe” pregnancy tests Hispanic women tend to rely more on signs and symptoms rather than tests More Afro American women experience others discovering the pregnancy Dangers and concerns Avoid going to funerals (Vietnamese?) Avoid reaching over one’s head (cord around neck) Avoiding drafts of air ( Haiti, Latinamerica, Asian) Avoid sexual intercourse ( several Asian cultures and Latinamerican) Walking at certain times of day ( penetration by spirits) Avoid certain people who have powers Not talk about the baby before the birth, a certain time, or not to mention the name Not to have picture taken FEAR of transgressing taboos In some cultures a hot state, eating “hot” foods, or avoid them (India?) Obey “cravings” , avoid frustrations or baby will have certain characteristics There may be difficulty to carry out certain culturally prescribed practices ( e.g. dietary, massages, baths, etc.) Maybe conflict over: abiding by cultural prescriptions or adopting a more modern attitude Issues of betrayal, loss, nostalgia, or letting go of “old superstitions”.

Discomforts 1st trimester (see Teaching Guidelines 16-3)
Urinary frequency or incontinence Fatigue Nausea and vomiting Breast tenderness Nasal stuffiness and nosebleed (epistaxis) Increased vaginal discharge Ptyalism (excessive, often bitter salivation) Urinary frequency (see Teaching Guidelines 16-3) Void when urge is felt. Increase fluid intake during the day. Decrease fluid intake only in the evening to decrease nocturia. Fatigue Plan time for a nap or rest period daily Go to bed earlier. Seek family support and assistance with responsibilities so that more time is available to rest. Breast tenderness Wear supportive bra increase in size usually 1 to 2 cup sizes during pregnancy and lactation Nausea and vomiting Increased vaginal discharge Leukorrhea Daily bathing, cotton underwear, avoid douching Nasal stuffiness Cool air vaporizers, normal saline nasal spray Heartburn Avoid fried and fatty foods, eat small frequent meals, good posture

Discomforts 2nd & 3rd Trimesters
Heartburn (pyrosis) Ankle edema Varicose veins Hemorrhoids Constipation Backache Leg cramps Faintness Dyspnea Flatulence Carpal tunnel syndrome Heartburn (pyrosis) Eat small and more frequent meals. Use low-sodium antacids. Avoid overeating, fatty and fried foods, avoid lying down after eating, and sodium bicarbonate. Ankle edema Practice frequent dorsiflexion of feet when prolonged sitting or standing is necessary Elevate legs when sitting or resting. Avoid tight garters or restrictive bands around legs. Varicose veins Elevate legs frequently. Wear supportive hose. Avoid crossing legs at the knees, standing for long periods, garters, and hosiery with constrictive bands. Hemorrhoids Avoid constipation. Apply ice packs, topical ointments, anesthetic agents, Warm soaks, or sitz baths; gently reinsert into rectum as necessary. Constipation Increase fluids and roughage, daily exercise, dev. regular bowel habits Use stool softeners as recommended by physician. Backache Pelvic tilt exercise, good posture, avoid fatigue, good body mechanics when lifting Leg cramps Practice dorsiflexion of feet to stretch affected muscle. Faintness Avoid prolonged standing in warm or stuffy environments. Evaluate hematocrit and hemoglobin. Dyspnea Use proper posture when sitting and standing. Sleep propped up with pillows for relief if problem occurs at night. Flatulence Avoid gas-forming foods. Chew food thoroughly Get regular daily exercise. Maintain normal bowel habits. Carpal tunnel syndrome Avoid aggravating hand movements. Use splint as prescribed. Elevate affected arm.

Assessment of Fetal Well-Being
Ultrasonography (see Figure 21-1 & 21-2) Doppler flow studies Alpha-fetoprotein analysis Marker screening tests Count Fetal movements Amniocentesis (see Figure 21-19) Chorionic villus sampling (CVS) Percutaneous umbilical blood sampling (PUBS) Nonstress test Contraction stress test Biophysical profile Fetal lung maturity Handout provided on Bb

Role of the Nurse Risk assessment
Formulating nursing diagnosis The pregnant woman, her fetus, and her family are clients Educator & support person during testing Preparing her for the procedure Interpreting the findings Providing psychosocial support Assistant to the physician May perform testing Educator & support person when the woman is undergoing antenatal testing procedures May perform testing (with additional training) Provide time to ask questions, voice concerns Encourage woman and partner to bring list of questions, concerns to visits

Health Promotion Education During Pregnancy
Fetal Activity Monitoring Breast Care Clothing Bathing Travel Activity and Rest Exercises to Prepare for Childbirth Sexual Activity Dental Care Employment Immunizations Safe to give Unsafe to give Complementary & Alternative Therapies Fetal Activity Monitoring Monitor their unborn child’s well-being by regularly assessing fetal activity beginning at 28 weeks’ gestation. Vigorous fetal activity generally provides reassurance of fetal well-being Breast Care By good support. ,straps are wide and do not stretch Cleanliness of the breasts is important, esp. begins producing colostrum. Warm water. Should not use soap on her nipples because of its drying effect. Breast shields designed to correct inverted nipples can be effective but some women gain little or no benefit from them Clothing Clothing should be loose and non constricting. . Tight leg bands on girdles should be avoided. High-heeled shoes aggravate back discomfort by increasing the curvature of the spine. Bathing Important because of the increased perspiration and mucoid vaginal discharge that occurs during pregnancy. Rubber tub mats and handgrips for safety In the presence of vaginal bleeding or when the membranes are ruptured. Tub baths are contraindicated Travel Activity and Rest Helps maintain maternal fitness and muscle tone Certain conditions do contraindicate exercise Exercises to Prepare for Childbirth Pelvic tilt, or pelvic rocking, helps prevent or reduce back strain and strengthens abdominal muscle tone. Kegel exercises., “tailor sit” Sexual Activity Many women have no desire for sex because of fatigue, nausea and vomiting or changes in body image. Others enjoy sex more because they are not afraid of getting pregnant or the changes in estrogen levels heighten orgasm. No sex: vaginal bleeding, Risk of PTL, Premature ROM, placenta previa, Presence of infection, mult. gestation Routine vaccines that generally are safe to administer during pregnancy include diphtheria, tetanus, influenza, and hepatitis B. Vaccines that are contraindicated, because of the theoretic risk of fetal transmission, include measles, mumps, and rubella; varicella; and bacille Calmette-Guérin. Physicians consider vaccinating pregnant women on the basis of the risks of vaccination versus the benefits of protection in each particular situation, regardless of whether live or inactivated vaccines are used. Dental Maintain good oral hygiene by brushing at least twice a day and flossing daily. Eat a healthy diet . ! Teeth cleaned every 6 months. Travel Stop every 2 hours and walk around for approximately 10 minutes. Airlines permit pregnant women to fiy up to 36 weeks’ Travel by airplane or train is generally recommended for long distances Prior to international travel, pregnant women should consult with their healthcare providers

Teratogen Teratogen – adverse effects to fetal development Medications
First trimester greatest risk FDA categories A B C D X Tobacco Alcohol Caffeine Marijuana Cocaine Nonjudgmental approach Tobacco Modifiable cause of poor pregnancy outcomes Public health education Campaigns in the United States, smoking during pregnancy has decreased significantly. Five A’s Ask about tobacco use. Advise to quit smoking. Assess willingness to quit. Assist in attempt to quit. Arrange for follow-up care. More than 10 cigarettes/day – nicotine replacement? Educational resources ETOH One of primary teratogens in Western world Fetal alcohol syndrome (FAS) Alcohol passes placental barrier within minutes Fetal blood alcohol level equivalent to maternal blood alcohol level Assessment with prenatal history Evaluation Essential part of effective nursing care Recognize situations that require referral Ongoing and cyclic nature of nursing process

Critical Periods of Development
Weeks gestation from LMP Most susceptible Central Nervous System Central Nervous System time for major malformation Heart Heart Arms Arms Eyes Eyes Legs Legs Teeth Teeth The heart begins to beat at 22 days after conception, and the neural tube closes by 28 days after conception. If you do the math, that’s 5 to 6 weeks after the last menstrual period for women with 28-day cycles. Most women haven’t started prenatal care yet, and many women aren’t even aware that they are pregnant, and yet some of the most vital organs are already formed. This is why early prenatal care is too late. By the time the woman comes in for prenatal care, there may not be much you can do about preventing some birth defects. Teratogenesis: development of developmental defects Palate Palate External genitalia External genitalia Ear Ear Missed Period Mean Entry into Prenatal Care

AMA over 35 Contributing Factors Advantages Risks
Increased risk for Gestational diabetes mellitus Hypertension Placenta previa Difficult labor Newborn complications Possibility of Unhealthy Child Pregnancy factors Availability of effective birth control methods Career options available for women Increased number of women Obtaining advanced education Pursuing careers Delaying parenthood Increased incidence of later marriage and second marriage High cost of living Increased number of women in this older reproductive age group Increased availability of specialized fertilization procedures Advantages Tend to be well educated and financially secure More aware of realities of having a child Feel secure about taking on added responsibility of child May be ready to stay home with new baby Can afford good child care Risks More likely to have chronic medical conditions Increased incidence of low-birth-weight and preterm infants Increased rate of miscarriage Increased risk of cesarean delivery Increased risk of having an infant with Down syndrome Amniocentesis, chorionic villus sampling (CVS) Decision to have abortion Support of couple Ensure couple aware of risks, has complete information

Special Concerns of Expectant Couples over 35
Energy to care for new baby Ability to deal with needs of older child Financial concerns of college and retirement May feel socially isolated Response of other children and family Healthcare professionals Limited time to bear children

Nursing DX Health-seeking behaviors Knowledge deficit
Risk for injury to fetus Decisional conflict Risk for ineffective family coping

Risk Factors Age Medicines/Drugs Tobacco/Alcohol Chronic Disorders
Poor Nutrition Late prenatal care Complicated OB/GYN history

Weight Gain Not all the weight gain during pregnancy is the baby's weight; most of it is used by your body to nourish and support a healthy baby. The diagram below explains how and where your baby weight is distributed. When concerned about weight gain the client should keep a dairy: keep a 3-day food diary to bring in to her next visit in 1 week. Being overweight or obese can substantially increase perinatal risk: a. Preeclampsia b. Hemorrhage c. Difficult delivery

Factors Influencing Nutrition
Salmonella and listeria infection Salmonella in raw eggs  pregnant women advised to avoid foods that may contain raw, lightly cooked eggs Listeria monocytogenes risk to expectant mother and fetus Uncooked soft cheese may harbor Listeria. Lactose intolerance  inadequate amount of enzyme lactase Cultural, ethnic, religious influences Psychosocial factors Eating disorders Common discomforts of pregnancy Herbal, botanical, alternative therapies Use of artificial sweeteners Generally Recognized As Safe (GRAS) by FDA Acesulfame potassium Aspartame Saccharin Sucralose Stevia newest low-calorie sweetener Mercury in fish Common discomforts of pregnancy GI discomfort Herbal, botanical, alternative therapies Caution with pregnant consumer Use of artificial sweeteners Generally Recognized As Safe (GRAS) by FDA Stevia newest low-calorie sweetener FDA approved Mercury in fish: Can pose threat to fetal brain Recommendations Do not eat swordfish, shark, tilefish, king mackerel Eat up to 12 oz/week of variety of shellfish, fish lower in mercury Canned light tuna, Shrimp, Salmon, Catfish, Pollack Check advisories for locally caught fish Salmonella and listeria infection Immune system slightly compromised in pregnancy Salmonella in raw eggs  pregnant women advised to avoid foods that may contain raw, lightly cooked eggs Listeria monocytogenes risk to expectant mother and fetus Maintain refrigerator temperature at 40°F (4°C ) or below Freezer at 0°F (–18°C) Refrigerate or freeze prepared foods, leftovers, perishables within 2 hours of eating or preparation Do not eat hot dogs, luncheon meats unless reheated until steaming hot Avoid soft cheeses such as feta, brie, Camembert, blue veined cheeses, queso fresco or queso blanco unless label clearly states made with pasteurized milk Do not eat refrigerated pâtés, meat spreads, or foods containing raw milk Avoid eating refrigerated smoked seafood (salmon, trout, cod, tuna, mackerel) unless in cooked dish Canned or shelf-stable pâtés, meat spreads, smoked seafood considered safe to eat Lactase deficiency Lactose intolerance  inadequate amount of enzyme lactase Common: African Americans, Hispanic Americans, American Indians, Asian Americans Abdominal distension, nausea, vomiting, loose stools, cramps Cultural, ethnic, religious influences Different nationalities accustomed to eating foods available in country of origin Certain foods have symbolic significance related to major life experience, developmental milestone Nurse needs to understand cultural influences on woman’s eating habits Psychosocial factors Sharing of food  friendliness, warmth, social acceptance Socioeconomic level may be determinant of nutritional status Knowledge about basic components of balanced diet essential Attitudes and feelings about pregnancy  influence nutritional status Eating disorders

Nutrition and weight management play an essential role in the development of a healthy pregnancy.
Not only does the patient need to have an understanding of the essential nutritional elements, she must also be able to assess and modify her diet for the developing fetus and her own nutritional maintenance. To facilitate this process, it is the nurse’s responsibility to provide education and counseling concerning dietary intake, weight management, and potentially harmful nutritional practices. To facilitate this process, it is the nurse’s responsibility to gather more information on the woman’s dietary practices through a food diary.

Nutritional Needs Dietary recommendations
Increase in protein, iron, folate, and calories (see Table 18-1) USDA’s Food Guide Pyramid (see Figure 18-2) Avoidance of some fish Water and fluids 8 glasses per day No alcohol or tobacco Limit caffeine Use prenatal vitamins Daily Food Plan for pregnancy and Lactation (Table 18-3) Client Education Special Considerations Cultural variations Lactose intolerance Vegetarianism Pica Direct effect of nutritional intake on fetal well-being and birth outcome Need for prenatal vitamin and mineral supplement daily Iron can cause constipation Folic acid to prevent neural tube defects The incidence of spina bifida is much higher in women with poor folic acid intakes. It is a priority that this patient receives nutrition counseling. Dietary recommendations Increase in protein, iron, folate, and calories (see Table 18-1) Use of USDA’s Food Guide Pyramid (see Figure 18-2) Avoidance of some fish due to mercury content Water and fluids 8 glasses per day Patients should be encouraged to drink at least 8 to 10 glasses of water each day empty their bladders at least every 2 to 3 hours immediately after intercourse. These measures will help prevent stasis of urine and the bacterial contamination that leads to infection, as well as constipation. Some women experience symptoms of fatigue that can be alleviated by remaining adequately hydrated. No alcohol, no unprescribed drugs or the counter or otherwise, No smoking, limit caffeine Client Education Special considerations Cultural variations Lactose intolerance Vegetarianism Pica

Nutritional Care of the Pregnant Adolescent
Risk factors interrelated More likely to be underweight Nutrition-related assessment Supplements are required Irregular eating patterns Counseling Risk factors interrelated Emotional Social Economic More likely to be underweight Nutrition-related assessment Iron supplements are required Calcium supplements are required Irregular eating patterns must be assessed over time Counseling Positive approach Suggest nutrient-rich foods Include other family members involved in meal preparation Involve expectant father Emphasize benefits to her and her baby Peer classes

Postpartum Nutrition Assessment Formula Feeding Breastfeeding
Increase caloric intake by 200 kcal/day over pregnancy level Protein intake Calcium intake Iron intake Maintain adequate fluid intake Assess new mother’s weight, labs, clinical signs Weight loss at birth Rate of weight loss Evaluate weight Assess clinical symptoms Formula Feeding Dietary requirements return to prepregnancy levels Understanding of nutrition Refer to dietitian if excessive weight gain Nutrient needs increase during breastfeeding Increase caloric intake by 200 kcal/day over pregnancy level Protein intake – 65 mg/day for first 6 months and then 62 mg/day thereafter Calcium intake should be 1000 mg/day Iron intake Maintain adequate fluid intake

Nursing DX Imbalanced Nutrition: Less than Body Requirements
Imbalanced Nutrition: More than Body Requirements Readiness for Enhanced Knowledge Imbalanced Nutrition: Less than Body Requirements Imbalanced Nutrition: More than Body Requirements Readiness for Enhanced Knowledge

References Davidson, M. London, M & Ladewig, P. (2012)
Olds' Maternal-Newborn Nursing & Women's Health Across the Lifespan (9th edition). New Jersey: Pearson Education, Inc.

GTPAL 3. A woman’s obstetric history indicates that she is pregnant for the fourth time, and all her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system?

b. January 12, 2008 c. December 12, 2007 d. December 9, 2007
4. A new obstetric client states that her last period started on March 5, 2007 and ended on March 9, What is her estimated date of birth (EDB)? a. December 5, 2007 b. January 12, 2008 c. December 12, 2007 d. December 9, 2007 Correct answer: C Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

5. A nurse is obtaining a gravida/para history on a new obstetric client. She has had a 6-week abortion, a 33-week pregnancy that ended in a stillbirth, and a 36-week pregnancy that resulted in a baby girl who is alive and well. What is her GTPAL? a. G3 T1 P1 A1 L2 b. G3 T0 P2 A1 L1 c. G4 T1 P1 A1 L2 d. G4 T0 P2 A1 L1 Correct answer: D

6. The nurse is performing an assessment on a client at 28 weeks of gestation and notices that the client has hyperpigmented areas on her face. The nurse would record this finding as: a. chloasma. b. linea nigra. c. striae gravidarum. d.epulis. Correct answer: A

Level with the umbilicus Halfway between the symphysis and umbilicus
The nurse is assessing the fundal height of a client at 26 weeks' gestation. The nurse should expect the fundus to be: Level with the umbilicus Halfway between the symphysis and umbilicus Slightly below the ensiform cartilage At 26 cm 26 cm. Fundal height in centimeters correlates well with weeks of gestation between 22–24 weeks and 34 weeks. Thus, at 26 weeks' gestation, fundal height is probably about 26 cm.

An antepartum client tells the nurse her last period was May 18
An antepartum client tells the nurse her last period was May 18. The nurse uses Ngele's rule to compute the client's expected date of birth, and tells the client that the correct date of birth will be: February 11 (of the next year) February 18 (of the next year) February 25 (of next year) February 28(of next year) February 25 (of the next year) is the correct date of birth based on the fact that the first day of her last period was May 18. Calculating with Nagele's rule (subtract 3 months first, then add 7 days to the first day of the last menstrual period) provides for the EDB of February 25.

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Assessment of Fetal Well-Being Click here to add text Chapter 21 min diagnostic testing Click here to add text. Click here to add text.

Antepartal Testing Review Chart found on Bb.

Ultrasound

Amniocentesis at weeks, amniotic fluid sample removed from uterus used to assess: genetic diagnosis, fetal lung maturity, fetal well-being - genetic disorders: trisomies, metabolic disorders, neural tube defects - fetal lung maturity: L:S ratio (2:1) and presence of prostaglandins (PG) after 35 weeks is most accurate determination - fetal well-being: bilirubin delta optical density, meconium may indicate fetal distress nursing implications: supine position, use of Betadine to sterilize site, label samples, monitor FHR 1 hour after procedure; ***if amniocentesis is done in early pregnancy, bladder must be FULL; it done in late pregnancy, bladder must be EMPTY to prevent puncture complications: spontaneous abortion, fetal injury, infection

Fetal Lung Maturity Lecithin to Sphingomyelin ratio (L/S ratio) > 2:1 Amniocentesis

The Non-Stress Test Antepartum fetal assessment test used to assess fetal well being FHR is monitored for 2 accelerations in a 20 minute period In the fetus greater than 32 weeks FHR must be 15 beats above baseline for at least 15 seconds - Reactive For fetus less than 32 weeks FHR must be at least 10 beats above baseline for at least 10 seconds If criteria met, FMR is said to be reactive If criteria is not met, FMR is non-reactive and requires further assessment and interventions

CHORIONIC VILLI SAMPLING (CVS)
at 8 to 12 weeks gestation, a small piece of villi is removed guided under an US determines genetic diagnosis in the first trimester nursing implications: lithotomy position, patient may feel sharp pain when catheter inserted complications: spontaneous abortion

ELECTRONIC FETAL MONITORING (EFM)
variables of EFM: - contractions – duration, frequency, intensity - baseline fetal heart rate (FHR) – , measured over 10 minutes variability: absent, minimal (< 5 bpm) , moderate (6-25 bpm), marked (>25 bpm) VEAL CHOP warning signs: absent or minimal FHR, bradycardia (< 110), tachycardia (>160), variable decelrations emergent signs: severe variable decelrations (FHR <70, lasting > 30-60s), late decelerations

Triple/quad screen

Percutaneous Umbilical Blood Sampling (PUBS)

Biophysical Profile(BPP)

Contraction stress test (CST)
Pitocin given to induce contractions Late decelerations + test Occurring in greater than 50% of UCs Indicate placental insufficiency Negative test No lates with minimum of 3 UCs lasting 40 to 60 secs within a 10 minute period

Doppler Flow Studies

Role play teaching scenarios for the patient undergoing the following procedures:
Chorionic villus sampling (CVS) Percutaneous umbilical blood sampling (PUBS) Biophysical profile (BPP) Doppler Flow Studies Ultrasound Fetal activity Amniocentesis Nonstress test (NST)—nonreactive, reactive Fetal Lung Maturity Contraction stress test

Antepartum Nursing Assessment Ch. 15 Kathleen Hughes RN WHNP

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Antepartum Nursing Assessment Ch. 15 Kathleen Hughes RN WHNP

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