Antepartal /Prenatal

 Initial visit
1.Complete history and physical
2. Obstetric history
G = total pregnancies
T = number of term infants (37 weeks of
gestation
P = number of preterm infants
A = number of spontaneous or therapeutic
abortions
L = number of living children
 Important Estimates
Naegele’s rule – use to determine the
expected date of delivery
Get the LMP – 1st day of the last menstrual period
Formula:
April – December = -3 + 7 + 1
McDonald’s Rule – to determine the age of gestation in wks.
Formula:
Height in cm of fundus in cm X 2/8 = lunar months

Height in cm of fundus in cm X 8/7 = wks

Johnson’s rule – to estimate fetal wt.
Formula:
Fundic ht. in cm –11 (not engaged) X 155
- 12 (engaged) X 155
Age of Gestation
Bartholomew’s – AOG
is estimated by the
position of uterus in the
abdominal cavity. Done
thru palpation.
Bartholomew’s Rule – to determine the AOG by the the proper location
of fundus in the abdominal cavity
3 months – fundus just above the symphisis pubis
5 months – level of umbilicus
9 months – below the xyphoid process
10 months – at the level of 8 mons ( due to lightening)
Haase’s Rule – to determine the length of the fetus in cm
Formula:
>on the 1st half of pregnancy, square each month
> on the 2nd half of pregnancy multiply each month by 5 (6 months onward)
Quickening:
Primi: date of Q +4mos + 20days
Multi: date of Q + 5mos + 4 days
 Schedule of return prenatal visit
1. Frequency of return prenatal visits.
1. Monthly for first 28 weeks or 7th month

2. Every 2 weeks to the 28th to 36th week; 7 & 9

mon
3. After 36th week or 9 mons, weekly until delivery.

1. Pattern of Weight
1. 1st trimester – 1.5 – 3 lbs
2. 2nd trimester – 10-12 lbs; 4lbs/ mon; 1 lb/wk
3. 3rd trimester - 10-12 lbs; 4lbs/ mon; 1 lb/wk
>if above, pattern for pre-eclampsia
DEFINITION OF COMMON TERMS
1. Gravida – pregnancy regardless of the duration; includes
the present pregnancy
2. Para- refers to past pregnancies that continue to the
period of viability.
3. Primigravida – woman who is pregnant for the first time.
4. Mutigtravida- woman who is pregnant for the 2nd or
subsequent time.
5. Nullipara – woman who has not had children
6. Primipara – woman who has carried a pregnancy to
viability.
7. Parturient – woman in labor.
Signs of Pregnancy
1. Presumptive Signs (subjective) – Suggestive of
pregnancy; these signs could be caused by other
conditions, so they do not establish a diagnosis of
pregnancy.
2. Probable Signs (Objective)- signs of pregnancy can
be documented by physical examination and are
signs that are more often only characteristic of
pregnancy; these findings could also be caused by
other conditions. Therefore do not establish a
diagnosis of pregnancy.
3. Positive Signs (diagnostic)– Physical findings that
establish a diagnosis of pregnancy
 Presumptive Sign
1. Amenorrhea
2. Nausea and Vomitting
3. Excessive fatigue
4. Urinary frequency
5. Breast changes – tenderness, fullness, increased
pigmentation of the areola.
6. Quickening – initially felt between 18 & 2o weeks of
gestation.
7. Linea nigra – may appear in midline of abdomen, from
symphysis pubis to umbilicus
8. Chloasma – commonly called as “mask of pregnancy”
9. Striae gravidarum- “stretch marks” are pink or purple
streaks on skin. Becomes silvery white after delivery.
 Probable Sign
1. Positive pregnancy test
2. Enlarge abdomen
3. Hegar’s sign – softening of lower uterine
segment
4. Chadwick’s sign – bluish discoloration of vagina
5. Goodell’s sign- softening of cervix or cervical lip
6. Ballottement – pushing on fetus (4th to 5th month)
and feeling it rebound back
7. Braxton-Hicks contractions –painless irregular
contractions.
Positive Sign
1. Fetal heart tone- 10th to 12th (doppler);
18th to 20th week (fetoscope)
2. Fetal movements
3. Fetal Outline
4. Fetal parts palpable
5. Ultrasound evidence (Sonogram)
Nutrition in Pregnancy
Additional 300 calories per day
Proteins – RDA: 60 g
Iron – 30 mg/day
Carbohydrates – RDA: 300-400 g
Calcium – 1,200 mg
Fats – RDA: 90 g
Phosphorus – 1,200 mg
Minerals
Iodine – 175 mcg
Vitamins
Selenium- 65 mcg

Vitamin A – 600 C Vitamin C – 70 mg Vitamin B6 – 2.2 mg

Vitamin D – 10 mcg Thiamine – 1.5 mg Folic Acid – 400 mcg
Vitamin E – 10 mcg Riboflavin – 1.6 mg Vitamin B12 – 2.2 mcg
Vitamin K – 65 mcg Niacin – 17 mg NE
Nutrition in Pregnancy
It is important to note that the woman’s blood
volume increases during pregnancy so that folic
acid needs also increase. Megaloblastic anemia
(large yet ineffective red blood cells) results from
inadequate folic acid intake. Folic acid is
important in preventing neural tube defects.
Foods rich in folic acid include fruits and
vegetables.
 Ultrasound
> uses reflected sound waves as they travel in tissues to
produce a picture.

> Can identify a pregnancy as early as 5 weeks. At 7th week fetal

parts can be recognized.

> Use to detect multiple pregnancy, fetal abnormality, H-mole,

Fetal death, presentation and position and fetal weight.

> Use to determine fetal maturity using biparietal diameter

( BPD). BPD of > 0.92cm has been correlated with mature fetal
lung.

> Abdominal transverse diameter is important when there is

stress and head growth is spared and body wasting occurs.
Head and Abdomen ratio is also used: H/A ratio of 1.0 is
correlated with gestation greater than 36weeks.
 EVALUATION OF FETAL
WELL-BEING
ULTRASONOGRAPHY
Transducer on abdomen transmits sound waves that show fetal
image on screen.
Provide useful information when assessing fetal growth and well-
being. It provides direct information about the fetus during each
trimester.
FIRST TRIMESTER
 Assessment of gestational age.
 Evaluation for congenital anomalies.
 Diagnostic evaluation of vaginal bleeding.
 Confirmation of suspected multiple gestation.
 Evaluation of fetal growth.
 Adjunct to prenatal testing (Amniocentesis or chorionic villi
sampling)
 EVALUATION OF FETAL
WELL-BEING
ULTRASONOGRAPHY
SECOND TRIMESTER
Assessment of gestational age.
Evaluation for congenital anomalies (hydrocephaly)
Assessment for fetal growth.
Guidance of procedures (Amniocentesis and fetoscopy)
Assessment of placental location.
Diagnosis of multiple gestation.
THIRD TRIMESTER
Determination of fetal position.
Estimation of fetal size.
 Fetal Assessment
 Fetal Heart Tone
*FHR should be 120-160 beats per minute
throughout the pregnancy.
*Can be heard as early as 11th-12th week by
the use of an ultrasonic Doppler technique.
*Variabilities:
 Decreased variability  CNS depression ( often due to
meds).
 Early deceleration  Not caused by hypoxemia nor can
result to poor fetal outcome.
 Late deceleration  fetal hypoxemia and distress; due to
preeclampsia, maternal hypotension, excessive uterine
contraction.
 Assessment of FHR can be done through:
 Rhythm Strip Testing
 FHR is assessed in terms of baseline and long-
and- short term variability.

Baseline reading means the average rate of the

fetal heart beat per minute.

 Short term variability denotes the small changes in

rate that occur from second to second.

 Long term variability denotes the difference in

heart rate that occur over a 10- or – 20 minute time
period.
  Non – Stress Testing

 done in 10 minutes to note the response of FHR to fetal movement.

 As fetus moves, FHR should be increased by 15 beats per minute

and remain elevated for 15 seconds, then return to its pattern as the fetus
quiets.

 The test is reactive if 2 accelerations of fetal heart rate lasting for 15

seconds occur following movement within 10 minutes period.

 The test is non – reactive if no accelerations occur with fetal

movements. Amniocentesis is indicated to check lung maturity.

 If 10 minute period passed without fetal movement, it means that the

fetus is sleeping. Give the mother oral carbohydrate snack to increase
the glucose level and stimulate fetal movement.
Procedure
1. place client in a semi-fowlers position
2. take baseline vital signs
3. place external monitor over fundus of uterus
4. instruct client to press recording button each
time she feels fetal movement
5. normal test time is 20 – 30 minutes
6. record fetal heart rate and contractile activity
7. If no fetal heart rate may:
 Gently rub or palpate abdomen to stimulte
movement
 The mother may be asked to eat a light meal, as
increased blood sugar increases fetal activity.
EVALUATION:
1. Reactive – shows 2 or more accelerations of
15bpm or more w/in 20 min period
2. Nonreactive – criteria are not met.
 No FHR acceleration
 Acceleration is less than 15bpm
 The test is extended another 20 mins.
3. Unsatisfactory – FHR pattern not able to be
interpreted.
 Stress Test or OCT

 Determines fetal well being and fetal ability to withstand stress

of labor; Done for abnormal NST or at risk fetus; assesses
placental function.
 Monitoring requires indirect fetal external monitor ; and,
positioning is fowler’s position; Same as NST but with the use
of Oxytocin.
 Baseline and frequent maternal BP readings are taken; test
takes 1-3 hours with close monitoring until there’s contractions.
 Results:
 Negative ( normal ) – absence of late decelerations of FHR with
each of 3 contractions; negative window.
 Positive ( abnormal ) – presence of late decelerations of FHR
with 3 contractions during 10-minute period; positive window.
 Equivocal or suspicious – absence of positive or negative
window.
 Unsatisfactory – inadequate contractions ot tracing.
 High risk pregnancies continue with weekly negative tests.
Types
1. Nipple-stimulated CST
 Massage or rolling of one or both nipples to stimulate
2. Oxytocin Challenge test
 Infusion of calibrated dose of of IV oxytocin (0.5 Mu / min)
 Amount infused increased by 15-20 mins until 3 good uterine
contractions are observed w/in 10 min period.
Contraindications
1. 3rd trimester bleeding
2. Previous cesarean birth
3. Risk of preterm labor due to premature rupture of the
membranes, incompetent cervical os, or multiple gestation
PROCEDURE:
1. client is usually not admitted
2. place client in semi-Fowler’s position or lateral
recumbent position to prevent supine hypotensive
syndrome
3. give liquid nourishment if ordered
4. explain procedure to client
5. apply external fetal monitor
6. observe for uterine activity and fetal heart rate usually
for 10 – 20 minutes to obtain baseline
7. IV solution with oxytocic drug is started; infusion
pump usually used to more accurate dosage
8. Dosage is increased every 15 – 20 minutes until
client has three good contractions in a 10 minute
period. (Oxytocin is discontinued once patterns is
established)
9. Observe client for signs of sensitivity to drug
10. Record vital signs and oxytocic infusion every 15
minutes on strip
11. Monitor contractions and fetal heart rate until client
returns to preoxytocic state
12. Discontinue Iv and prepare client for discharge
13. Record all information on chart; monitor strip is
considered legal document and becomes part of
the chart
14. Discontinue drug immediately if fetal heart rate
decreases below 120 or sustained uterine
contraction develops
Evaluation:
1. 3 consecutive contractions in a 10 minute
period may take 1 – 3 hours
 Positive CST - reaction would be persistent
late decelerations or bradychardia
 if fetus cannot withstand mild contractions.
Caesarian delivery is indicated
 Negative (reassuring) –shows no late
decelerations after contraction; implies
placental support is adequate
 Fetal Movement

*Can be felt by the mother beginning 18th to 20th weeks of pregnancy

and reaches a peak at 29th to 38th weeks.

*Normally, 2 times every ten minutes that it can be counted to move 10-
12 times an hour.

*Any fetal movement fewer than 5 ( half the normal number ) in a

chosen hour of observation should be reported.

*Cardiff’s “count of ten” means that having less than 10 counts in 10

hours calls for further evaluation.

*Placental insufficiency will greatly decrease the fetal movement.

Maternal intake of depressant drugs, alcohol and smoking can reduce its
movement, too.

*Fetal movement are not usually present in sleeping fetus.

 Amniocentesis
> The aspiration of amniotic fluid from the
pregnant uterus for examination to determine
genetic disorder, sex, and fetal maturity ; done
from 14th weeks on.
> Timing of amniocentesis procedures:
Chromosomal determination - 14-16 weeks

Rh isoimmunization in Rh negative mothers

20-28 weeks
Maturity determination - 34-42 weeks

Assessment of fetal well being - 34-42 weeks

 Risks to client include: maternal hemorrhage, infection, Rh
isoimmunization, abruption placenta, labor, fetal death ( 0.3-
0.5% risk ), infection, injury from needle.

 Nursing Responsibilities:
Informed consent.
Have client empty bladder before procedure.
Baseline vital signs and FHR, then check every 15
minutes.
Ultrasound performed to locate placenta.
Positioned supine with abdominal scrub. A rolled towel
or pillow on right buttock to decrease pressure on vena cava
and aorta.
Rest and avoidance of strenuous activities like jogging
and aerobic exercises for 1-2 days.
Instruct client to report any side effects: chills, fever,
fluid leakage, decreased fetal movement, uterine contractions.
 Information from Amniocentesis:

 Significance of color
 Normally, the color of water. Yellow tinge
suggest blood incompatibility. A green color suggest
meconium staining.

 Lecithin / Sphingomyelin Ratio

 They are protein component of the lung
enzyme surfactant that the alveoli begin to form about the
22nd to 24th weeks of pregnancy.
 Normal ratio is 2:1 or greater which signifies
the fetal pulmonary system is sufficiently mature for birth.
There is adequate surfactant, phosphatidyl glycerol
(PD ), and phosphatidyllinositol ( PI ).
AMNIOCENTESIS
AMNIOCENTESIS
 Bilirubin Determination
 Normally, should be negative for blood or should
have no false-positive reading.

 Chromosome Analysis
 Chromosomal study of fetal tissues should be
free of diseases.

 Inborn error of Metabolism

 the enzyme defect must be present in the
amniotic fluid as early as 14-16th weeks to
have a diagnosis.

 Alpha fetoproteins
 Levels decreased after 13th week. If not: spina
bifida, anencephaly, and other neural tube disorders.
 Chorionic Villi Sampling
 Used to obtain samples of chorionic villi to test
for genetic disorders in fetus.

 Using an ultrasound picture, a catheter is

passed vaginally into woman’s uterus where a
sample villi tissue is snipped off by suction.

 Biopsy is performed between 10-12 weeks of

pregnancy.
 EVALUATION OF FETAL
WELL-BEING
CHORIONIC VILLI SAMPLING
Earliest test possible on fetal cells alternative to amniocentesis to
diagnose fetal karyotype and genetic anomalies (sickle-cell anemia,
PKU, Down syndrome, Duchenne muscular dystrophy).

Done between 10-12 weeks; before 10 weeks, higher incidence of

associated limb defects.

Complications:
Complications Bleeding, spontaneous abortion, premature rupture
of membranes.

Rh(-) mother receive RhoGAM after test to prevent Rh isoimmunization.

Ultrasound used to guide.

TEST RESULTS: Within 2-10 days.

Maternal
Urine
Assay Tests
> Estriol level from 24 hour urine collection.
> provides information on fetal, placental and maternal renal function.
> Levels are dependent on age of gestation, fetal and placental size,
multiple pregnancy, and adequacy of urine sample.
> Level of estriol that dropped between 40-50% within 1 week signify danger
to the fetus.

> Normal estroil level:

12 weeks- less than 1mg/ 24 hr.
16 weeks – 2-7
20 weeks - 4-9
24 weeks – 6-13
28 weeks – 8-22
32 weeks – 12-43
36 weeks – 14-45
40 weeks – 19-46
 Plasma Assay Test

> May be analyzed for alphafetoproteins.

Increased levels are associated with Rh and
ABO maternal immunization, fetoplacental
dysfunction, and fetal neural tube defects.
PSYCHOSOCIAL
ADAPTATIONS TO
PREGNANCY
 MATERNAL ADAPTATIONS TO
PREGNANCY
FIRST TRIMESTER
Ambivalence, fear, fantasies and anxiety
Pregnant woman places main focus on self.

SECOND TRIMESTER
Tranquil period
Acceptance of the reality of pregnancy
Increased interest in fetus

THIRD TRIMESTER
Anticipates labor and delivery; assumes mothering role
Fantasies and dreams about labor common.
Nestling behaviors
 DEVELOPMENTAL TASKS OF
PREGNANCY
“I AM PREGNANT”
acceptance of the biological fact of pregnancy

“I AM GOING TO HAVE A BABY”

acceptance of the fetus as a distinct individual and a person to care for.

“I AM GOING TO BE A MOTHER”
prepare realistically for the birth and parenting of the child.