PRENATAL CARE

Prepared by:
ROSELYN S. PACARDO, MAN, MM,RN, RM
 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
Presumptive Probable Positive

• Breast changes • Positive pregnancy • Sonographic evidence

• Morning sickness test of fetal outline
• Amenorrhea • Chadwick’s sign • Fetal heart audible
• Frequent urination • Goodell’s sign • Fetal movement felt by
• Fatigue • Hegar’s sign examiner
• Uterine • Sonographic
enlargement evidence of
• Quickening gestational sac
• Linea nigra • Ballotement
• Melasma/Chloasma • Braxton Hicks
• Striae Gravidarum contractions
• Fetal outline felt by
examiner
 - 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
• 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 11/21/09
Subtract 3 months 8/21/09
Add 7 days 8/28/09
Add 1 year 8/28/10 = EDB

- Gestational or birth calculator or wheel (see

Fig.)
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
- Primapara: 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
•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
M – multiple gestation
Physical Examination
•Vital signs
• Head-to-toe assessment
- Head and neck
- Chest
- Abdomen, including fundal
height if appropriate
- Extremities
• 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

• Solid line – diagonal

Conjugate

• Dotted line – true

conjugate
Pelvic Measurements
a. Diagonal Conjugate
b. True conjugate or
Conjugate vera
c. Ischial tuberosity
Note: Head’s diameter is 9 cm to be able to pass through the pelvis
• Distance between the anterior
surface of the sacral prominence and
the anterior surface of the inferior
margin of the symphisis pubis
• Anteroposterior diameter of the
pelvic inlet
• Measurement - 12.5 cm
• Measurement between the anterior surface
of the sacral prominence and the posterior
surface of the inferior margin of the
symphisis pubis
• Measurement – 10.5 to 11 cm
• Distance between the ischial tuberosities
• Transverse diameter of the outlet
• Measurement – 11 cm
Measurement of ischial tuberosity
 Laboratory Tests
•Urinalysis
• Complete blood count
• Blood typing
• Rh factor
• Rubella titer
• Hepatitis B surface antigen
• HIV, VDRL, and RPR (rapid
plasma reagin) testing
• Cervical smears
• Ultrasound
 Follow-up Visits
• Visit schedule:
- Every 4 weeks up to 28 weeks
- Every 2 weeks from 29 to 36 weeks
- Every week from 37 weeks to birth
• Assessments
- Weight & BP compared to baseline
values
- Urine testing for protein, glucose,
ketones, and nitrites
- Fundal Height
a. McDonald’s Method

Measure from the

top of the
symphisis pubis
to the top of the
uterus(in cm) then
divide by 4
b. Bartholomew’s Rule

Determines the relative

position of the uterus
in the abdominal cavity
- Leopold’s Maneuver
- Fetal Heart Rate
- Quickening/Fetal Movement

a.Cardiff Technique or Count to

Ten Method – record time
interval that mother feels ten
fetal movements; interval is
usually 60 minutes
b.Sadovsky Technique- fetus
usually moves twice every 10
minutes or average of 10 to 12
times an hour
 - Teach: Danger Signals
First Trimester Second Trimester Third Trimester

• Spotting or • Regular uterine • Sudden weight gain

bleeding(miscarriage) contractions (preterm • Periorbital or facial
• Painful urination labor) edema, severe abdomi-
(infection) • Pain in calf often nal pain, or headache
• Severe persistent increased with foot with visual changes (PIH)
vomiting (Hyperemesis flexion (blood clot in • Decrease in fetal
gravidarum) deep vein) daily movement for
• Fever higher than • sudden gush or leakage more than 24 hours
100 º F (infection) of fluid from vagina (possible demise)
• Lower abdominal (PROM) • Plus any danger signal
pain with dizziness • Absence of fetal Of the first and second
and shoulder pain movement for more than trimester
(ruptured ectopic 24 hours (possible fetal
pregnancy) distress or demise)
 Assessment of Fetal Well-Being
• Ultrasonography – Use of intermittent high frequency sound
waves by applying an alternating current
to a transducer made of piezoelectric
material

•Doppler Flow Studies - Measure the velocity of diastolic blood

flow within the umbilical vessels via
ultrasound

•Alpha-fetoprotein analysis -substance produced by the liver

between 13 and 20 weeks of
gestation

•Marker screening tests -a. Triple markers – AFP, unconjugated

estriol, and hCG done at 16 – 18 weeks;
detects Down’s syndrome

- b. Four markers -3 markers +inhibin A;

done at 14 to 22 weeks; detects Down’s
syndrome and neural tube defects
• Amniocentesis

Done at 14 –
16 weeks
Chorionic Villus Sampling (CVS)
Percutaneous Umbilical Blood Sampling
(PUBS)
Nonstress test;
Test results of the NST:

Test results of the NST may be:

reactive (normal) - two or more fetal
heart rate increases in the testing period
(usually 20 minutes).

nonreactive - there is no change in the

fetal heart rate when the fetus moves.
This may indicate a problem that
requires further testing.
Contraction Stress Test/Oxytocin Challenge Test

External fetal heart rate monitoring

Newest Trend: Nipple Stimulation

 - Contraction stress test

Normal:
Normal test results are called negative.
Your baby's heart rate does not get lower (decelerate) and stay
low after the contraction (late decelerations). Note: There may
be a few times during the test when your baby's heart rate
decelerates, but it doesn't stay low so it is not a problem.
If three contractions occur during a 10-minute period of nipple
stimulation or oxytocin infusion and there are no late
decelerations in your baby's heart rate, your baby is expected
to be able to tolerate the stress of labor.

Abnormal: Abnormal test results are called positive.

A slower heart rate (late decelerations) that stays low
after the contraction may mean that your baby will have
problems during normal labor. It may also mean that
your baby will develop problems if delivery is delayed.
Contractions that last longer than 90 seconds and occur
every few minutes are present. This is called
 - Biophysical Profile
a. Fetal Breathing – 30 sec of sustained breathing within 30 min

b. Fetal Movement – at least 3 separate episodes of fetal limb or

trunk movement within a 30 min observation

c. Fetal Tone – must extend then flex extremities or spine at

least once in 30 min

d. Amniotic Fluid Volume – a pocket of amniotic fluid measuring

more than 1 cm in vertical diameter must be present

e. Fetal Heart Reactivity – 2 or more HR accelerations of 15

beats/min above baseline and of 15 sec duration occur with
fetal movement over a 20-min period

Scoring System
Score of 2 for each item; 10 – highest score
 First-Trimester Discomforts
Urinary frequency or incontinence
Increased blood supply and
pressure on the bladder
Nasal stuffiness, bleeding gums,
epistaxis
Increased level of estrogen causing
edema and hyperemia of mucous
membranes
Leukorrhea
High levels of estrogen which
caused increased vascularity
and hypertrophy of cervical
glands and vaginal cells
 Kegel’s Exercise
 Empty bladder when feeling a full
sensation
 Avoid caffeinated drinks
 Reduce fluid intake after dinner
 Increase fluid intake
 Use cool mist humidifier at night
 Blow nostril gently, one at a time
 Avoid nasal decongestants and sprays
 Good oral hygiene, use soft-bristled
tooth brush, and floss daily
 Manage nose bleeding
 Keep perineal area clean and dry
 Wash with mild soap and water
 Avoid wearing pantyhose and tight-
fitting nylon clothes; avoid douches &
tampons
Fatigue
Increased O2 consumption;
Increased levels of
progesterone and relaxin;
increased metabolic
changes; psychosocial
changes, etc.
Nausea and vomiting
High levels of estrogen,
progesterone, hCG, and
vitamnin B6 deficiency;
Increased acidity, emotional
factors, and altered glucose
Metabolism
* Couvade Syndrome
Breast tenderness
Increased estrogen and
Progesterone levels
 Get a full night’s sleep.
 Eat a healthy balanced diet.
 Schedule a nap early in the
afternoon daily.
 When tired, get rest.
 Avoid an empty stomach at all times
 Eat dry crackers or toast before arising in AM
 Drink fluids between meals
 Avoid greasy, fried foods or ones with strong
odor
 Avoid spicy foods
 Avoid stress
 Wear a well supportive bra
even while sleeping
Constipation
Increased progesterone  Increase fluid intake
leads to decreased  High fiber diet
contractility of the GIT
Cravings  Exercise
causing water
absorption;
 Reduce cheese
Dietary factors;  Eat meals at regular interval
compression on colon  Decrease sugary sodas
by uterus; iron and  Drink warm fluids on arising
calcium

* Leg Cramps
 Instruct on importance of a
Increased hormone
levels healthy and balanced diet

* Pica
 Second-Trimester Discomforts
Backache
Shift in the center of gravity; high
level of progesterone softens joints
and cartilage; upper back pain
due to increased breast size
Varicosities of the vulva and legs
Increased venous stasis due to
pressure of the gravid uterus on
thepelvic vessels; vasodilation
caused by increased
progesterone levels
Hemorrhoids
Caused by progesterone- induced
vasodilation
Flatulence with bloating
Increased progesterone level causes
relaxation of GIT & dilatation
* SUPINE HYPOTENSION
 Proper posture with head up and
shoulders back
 Apply body mechanics
 When sitting, use foot supports
and pillows behind the back
 Pelvic tilt or rocking exercises to
strengthen the back
 Walk daily
 Elevate both legs above heart level
 Avoid prolonged standing
 Avoid constrictive clothing
 Avoid crossing legs
 Wear support stockings
 Vulva: elevate hips; knee-chest
 Regular bowel elimination
 Prevent straining
 Warm sitz
 Avoid gas-forming foods & foods
with high sugar
 Avoid chewing gum or smoking
 Third-Trimester Discomforts
Return of first-trimester
discomforts: fatigue, urinary
Frequency, and leukorrhea
Shortness of breath and dyspnea
Limited space for expansion of the
diaphragm
Heartburn and indigestion
High progesterone levels causes
relaxation of the cardiac sphincter
Dependent edema
Due to elevated hormone levels and
Increased blood volume
Braxton Hicks contractions
Irregular, painless uterine contractions
 Proper posture
 Avoid large meals
 Raising the head part or use pillows
 Avoid exercises precipitating dyspnea
 Avoid spicy or greasy foods
 Sleep using several pillows
 Avoid lying down for at least 2
hours after meals ; drink sips of water
 Elevate feet and legs
 Change position frequently
 Avoid foods rich in sodium
 Change position
 Engage in mild exercise
 Increase fluid intake
Nursing Management to Promote Self-Care

Personal hygiene
Avoidance of saunas and hot tubs
Perineal care
Dental care
Breast care
Clothing
Exercise
Sleep and rest
Sexual activity and sexuality
Employment
Travel
Immunizations and medications
Preparation for Labor, 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

Dick-Read (natural childbirth) method: focus on fear

reduction via knowledge and abdominal breathing
techniques
• Options for birth setting
- Hospitals: delivery room,
birthing suite
- Birth centers
- Home birth
• Options for care providers
- Obstetrician
- Midwife
-Doula
• Feeding choices
- Breastfeeding: advantages and
disadvantages
- Bottle feeding: advantages and
disadvantages
- Teaching

• Final preparation for labor and birth

 PSYCHOLOGICAL TASKS OF PREGNANCY

First Trimester Accepting the Pregnancy

Second Trimester
Accepting the Baby

Third Trimester Preparing for the Baby

and end of Pregnancy
16. Presumptive signs are known to be
caused by conditions other than
pregnancy. Subjective and presumptive
manifestations reported by a woman will
include all of the following, except:

A. Amenorrhea
B. Nausea and vomiting in early AM
C. Breast changes
D. Hegar’s sign
16. Presumptive signs are known to be caused
by conditions other than pregnancy. Subjective
and presumptive manifestations
reported by a woman will include all of the
following, except:
A. Amenorrhea
B. Nausea and vomiting in early AM
C. Breast changes
D. Hegar’s sign (– increased vascularity and
softening of the uterine isthmus)

Source: Pillitteri p. 223

Hegar’s sign
17. The last menstrual period of KC was
on Jan 18, 2010. Her estimated date of
birth would be on:
A. September 25, 2010
B. October 25, 2010
C. November 25, 2010
D. December 25, 2010
17. The last menstrual period of KC was
on Jan 18. , 2010. Her estimated date of
birth would be on:
A. September 25, 2010
B. October 25, 2010
C. November 25, 2010
D. December 25, 2010

Ricci p. 259
18. This is the third pregnancy of KC. She had a
miscarriage at 12 weeks and gave birth to a
son, now 3 years old, at 32 weeks.
She had no multiple gestation multiple
gestation. Using the GTPALM system, the
nurse would document this woman’s
obstetric history as:
A. 310211
B. 301110
C. 212120
D. 201111
18. This is the third pregnancy of KC. She had a miscarriage at 12
weeks and gave birth to a son, now 3 years old, at 32 weeks.
She had no multiple gestation multiple gestation. Using the
GTPALM system, the nurse would document this woman’s
obstetric history as:
A. 310211
B. 301110
C. 212120
D. 201111
The woman’s obstetric history would be documented as 301110:
G (gravida) = 3 (current pregnancy), T (term pregnancies) = 0,
P (number of preterm pregnancies) = 1, A (number of
pregnancies ending before 20 weeks viability) = 1,
L (number of living children) = 1, M (multiple gestation) = 0.

Pillitteri pp 252 - 253

19. A nurse in the health care clinic is instructing KC on
how to perform the “kick counts’. Which statement
made by KC indicates a need for further education?
A. “I should place my hands on the largest part of my
abdomen and concentrate on the fetal movements to
count the kicks.”
B. “I will record the number of fetal movements or
kicks.”
C. “I need to lie flat on my back to perform the
procedure.”
D. “A count of fewer than 3 fetal movements in 1 hour
indicates the need to contact the physician.”
19. A nurse in the health care clinic is instructing KC on how to
perform the “kick counts’. Which statement made
by KC indicates a need for further education?
A. “I should place my hands on the largest part of my abdomen
and concentrate on the fetal movements to count the kicks.”
B. “I will record the number of fetal movements or kicks.”
C. “I need to lie flat on my back to perform the procedure.”
(Side-lying position or left lateral recumbent)
D. “A count of fewer than 3 fetal movements in 1 hour indicates
the need to contact the physician.”

•Sadovsky method – the fetus moves twice every 10 minutes or

an average of 10 to 12 times in an hour;
•Cardiff Method or Count to Ten – feel at least 10 movements in
an interval of 60 minutes

Source: Ricci p. 266; Pillitteri p. 200

20. The nurse instructs KC that if she is
already on her second trimester of
pregnancy, she should return for
a follow-up visit every:

A. 4 weeks
B. 3 weeks
C. 2 weeks
D.Week
20. The nurse instructs KC that if she is already on
her second trimester of pregnancy, she should
return for
a follow-up visit every:
A. 4 weeks
B. 3 weeks
C. 2 weeks
D. Week

The recommended follow-up schedule is every 4

weeks up to 28 weeks, every 2 weeks from 29 to
36 weeks, and then every week from 37 weeks to
birth.

Ricci p. 265
SITUATION E: Nena is a primigravid woman who
experiences the common discomforts of
pregnancy. She went to the health center and
asks some recommendations on how to relieve
the discomforts.

21. After teaching Nena about ways to minimize

flatulence and bloating during pregnancy, which
statement indicates the need for additional
teaching?
A. “I’ll try to drink more fluids to help move
things along.”
B. “I’ll switch to chewing gum instead of using
mints.”
C. “I’ll stay away from foods like cabbage and
camote.”
D. “I’ll increase the time I spend walking each
day.”
SITUATION E: Nena is a primigravid woman who experiences the
common discomforts of pregnancy. She went to the health center
and asks some recommendations on how to relieve the
discomforts.

21. After teaching Nena about ways to minimize flatulence and

bloating during pregnancy, which statement indicates the need for
additional teaching?
A. “I’ll try to drink more fluids to help move things along.”
B. *“I’ll switch to chewing gum instead of using mints.”
C. “I’ll stay away from foods like cabbage and camote.”
D. “I’ll increase the time I spend walking each day.”
Eating mints can help reduce flatulence; chewing gum increases
the amount of air that is swallowed, increasing gas build-up.
Increasing fluid intake helps to reduce flatus. Gas-forming foods
such as beans, cabbage, onions and camote should be avoided.
Increasing physical exercise, such as walking, helps reduce flatus.

Ricci pp. 286 - 287

22. Which of the following interventions
would the nurse recommend to Nena who
is experiencing a severe heartburn during
her pregnancy?
A. Eat several small meals daily
B. Eat crackers on waking in the morning
C. Lie down immediately after eating
D. Drink orange juice frequently during
the day
22. Which of the following interventions would the nurse
recommend to Nena who is experiencing a severe
heartburn during her pregnancy?
A. Eat several small meals daily
B. Eat crackers on waking in the morning – for morning
sickness
C. Lie down immediately after eating – (rest at least for 2
hours)
D. Drink orange juice frequently during the day – drink
sips of water

Source: Pillitteri p. 315; Ricci p. 281

23. A nurse is providing instructions to Nena
regarding measures that will assist in
relieving backaches. Which statement made
by the client indicates a need for further
education?

A. “I need to try to maintain a good posture.”

B. “I should do more vigorous exercise to
strengthen my back muscles.”
C. “I should sleep on a firm mattress.”
D. “I should wear low-heeled shoes.”
23. A nurse is providing instructions to Nena
regarding measures that will assist in relieving
backaches.
Which statement made by the client indicates a need
for further education?

A. “I need to try to maintain a good posture.”

B. “I should do more vigorous exercise to
strengthen my back muscles.”(Moderate only;
Pelvic Rocking)
C. “I should sleep on a firm mattress.”
D. “I should wear low-heeled shoes.”

Source: Pillitteri p. 276

Pelvic Rocking
24.Which of the following is the recommended weight gain
per trimester of pregnancy that Nena should attain?

A. Three pounds for the first trimester, 12 pounds for the 2nd
trimester, and 12 pounds for the last trimester of pregnancy
B. One pound for the first trimester, 10 pounds for the 2nd
trimester, 15 pounds for the last trimester of pregnancy
C. Two pounds for the first trimester, 11 pounds for the 2nd
trimester, and 13 pounds for the last trimester of pregnancy
D. Four pounds for the first trimester, 13 pounds for the 2nd
trimester, and 14 pounds for the last trimester of pregnancy
24.Which of the following is the recommended weight gain per
trimester of pregnancy that Nena should attain?
A. Three pounds for the first trimester, 12 pounds for the 2nd
trimester, and 12 pounds for the last trimester of pregnancy
(3-12-12)
B. One pound for the first trimester, 10 pounds for the 2nd trimester,
15 pounds for the last trimester of pregnancy
C. Two pounds for the first trimester, 11 pounds for the 2nd trimester,
and 13 pounds for the last trimester of pregnancy
D. Four pounds for the first trimester, 13 pounds for the 2nd
trimester, and 14 pounds for the last trimester of pregnancy

Source: Pillitteri p. 302

25. Anticipatory guidance during the first
trimester of pregnancy is primarily directed
toward increasing the pregnant woman’s
knowledge of:

A. Labor and delivery

B. Signs of complications
C. Role transition into parenthood
D. Physical changes resulting from pregnancy
25. Anticipatory guidance during the first trimester of
pregnancy is primarily directed toward increasing the
pregnant
woman’s knowledge of:
A. Labor and delivery
B. Signs of complications
C. Role transition into parenthood – Preparing for
parenthood (Third trimester psychological task)
D. Physical changes resulting from pregnancy –
Accepting the pregnancy (First trimester psychological
task)

Source: Pillitteri p. 215(Second trimester – accepting the

baby)