CMCA – LEC 2) Family profile

Nursing Care during Normal Pregnancy and Care of the
Developing Fetus (ANTEPARTUM)
Determination of estimated birth date:
 Naegele’s Rule
To calculate the date of birth by this rule, count
backward 3 calendar months from the first day of a
woman’s last menstrual period and add 7 days.
For example, if the last menstrual period began May 15,
you would count back 3 months (April 15, March 15,
February 15) and add 7 days, to arrive at the predicted
date of birth as February 22.
 identify support system, size of house, her age &
partner’s age, educational levels, occupation
3) Family history
 Inherited disease
 Congenital Anomalies
Antepartum Assessment & Care
Past medical history
 Cardiac, kidney, STD’s, DM, Thyroid, Respiratory,
Surgical procedures, Injuries, Childhood Diseases,
and Allergies/ drugs and sensitivities.

Example: Social profile

Liz Calhorn first came to the prenatal clinic on August 5 Information of woman’s lifestyle
and told the nurse she had her last menstrual period  Exercise
from March 13 to March 18. What would be her child’s  Hobbies
EDB?  Smoking
 Drinking habits
Assessment of Fetal Growth and Development:  Medication history
Tests for fetal growth and development are commonly  Recreational drugs
done for a variety of reasons, including to:
• Predict the outcome of the pregnancy Gynecologic history
• Manage the remaining weeks of the pregnancy  Reproductive tract
• Plan for possible complications at birth  Breast problem
• Plan for problems that may occur in the newborn  Menarche
infant  Menstrual cycle (interval, duration, amount,
• Decide whether to continue the pregnancy discomfort)
• Find conditions that may affect future pregnancies  Past surgery on reproductive tract
 Reproductive planning method
Nursing responsibilities for these assessment  Sexual history
procedures include:
 verifying that a signed consent form has been Obstetric history
obtained as needed (which is necessary if the  G - # of pregnancies
procedure poses any risk to the mother or fetus that  P- # of delivered (viable)
would not otherwise be present)  T – term pregnancy
• being certain the woman and her support  P – preterm pregnancy
person are aware of what the procedure will entail  A – abortion
and any potential risks, preparing the woman  L – living children
physically and psychologically  M – multiple pregnancies
• providing support during the procedure,
assessing both fetal and maternal responses during Fetal Growth
and after the procedure As a fetus grows, the uterus expands to accommodate
• providing any necessary follow-up care, and its size.
managing equipment and specimens. Fundal (top of the uterus) measurements are:
 Over the symphysis pubis at 12 weeks
Health Assessment During the First Prenatal Visit:  At the umbilicus at 20 weeks
 At the xiphoid process at 36 weeks
1) Demographic Data
 address, telephone number, race/ethnic group, McDonald’s rule
religion, health insurance  another symphysis–fundal height measurement
 easy method of determining midpregnancy growth.
 tape measurement from the notch of the symphysis
pubis to over the top of the uterine fundus as a
woman lies supine is equal to the week of gestation
in centimeters between the 20th and 31st weeks of
pregnancy
 e.g., in a pregnancy of 24 weeks, the fundal height
should be 24 cm)
Mc Donald’s rule
 lunar months
 fundal height(cm) x 2/7
 ex: 14 cm x 2/7 = 4 months
Mc Donald’s rule
 weeks:
 fundal height (cm)x8/7
 ex: 14 cm x 8/7 = 16 weeks
A fundal height much greater than this standard
suggests a multiple pregnancy, a miscalculated due
date, a large-for-gestational-age (LGA) infant,
hydramnios (increased amniotic fluid volume), or
possibly even gestational trophoblastic disease
ASSESSING FETAL WELL-BEING
Fetal Heart Rate - heart sounds can be heard and
counted as early as the 10th to 11th week of pregnancy
by the use of an ultrasound Doppler technique
This is done routinely at every prenatal visit past 10
weeks.
1. Fetal heart tones
- A very rapid, somewhat muffled ticking sound normal:
120-160 bpm
2. Uterine bruit/ Souffle
- A soft murmur caused by the passage of blood thru the
uterine vessels
- Synchronous with maternal pulse
3. Funic Souffle
- Hissing sound produced by passage of blood thru the
umbilical arteries
- Synchronous with FHB
Daily Fetal Movement Count (Kick Counts)
 Fetal movement that can be felt by the mother
(quickening) occurs at approximately 18 to 20 weeks
of pregnancy and peaks in intensity at 28 to 38
weeks.
Rhythm Strip Testing
 The term “rhythm strip testing” refers to an
assessment of fetal well-being and assesses the fetal
heart rate for a normal baseline rate.
 Attach an external fetal heart rate monitor. Record
the fetal heart rate for 20 minutes.
Nonstress Testing
 A nonstress test measures the response of the fetal
heart rate to fetal movement.
 Position the woman and attach both a fetal heart
rate and a uterine contraction monitor.
Vibroacoustic Stimulation
 For acoustic (sound) stimulation, a specially
designed acoustic stimulator is applied to the
mother’s abdomen to produce a sharp sound of
approximately 80 dB at a frequency of 80 Hz, thus
startling and waking the fetus
Ultrasonography
 Ultrasonography, which measures the response of
sound waves against solid objects, is a much-used
tool for fetal health assessments.
Ultrasound can be used to:
o Diagnose pregnancy as early as 6 weeks gestation.
o Confirm the presence, size, and location of the
placenta and amniotic fluid.
o Establish a fetus is growing and has no gross
anomalies such as hydrocephalus; anencephaly; or
spinal cord, heart, kidney, and bladder concerns.
o Establish the sex if a penis is revealed.
o Establish the presentation and position of the fetus.
o Predict gestational age by measurement of the
biparietal diameter of the head or crown-to-rump
measurement.
o Discover complications of pregnancy, such as the
presence of an intrauterine device, hydramnios
(excessive amniotic fluid) or oligohydramnios
(lessened amniotic fluid), ectopic pregnancy, missed
miscarriage, abdominal pregnancy, placenta previa
(a low-implanted placenta), premature separation of
the placenta, coexisting uterine tumors, or multiple
pregnancy.
o Genetic disorders such as Down syndrome and fetal
anomalies such as neural tube disorders,
diaphragmatic hernia, or urethral stenosis also can
be diagnosed.
o Fetal death can be revealed by a lack of heartbeat
and respiratory movement.
o After birth, a sonogram may be used to detect a
retained placenta or poor uterine involution in the
new mother.
Biophysical Profile
A biophysical profile combines five parameters (i.e.,
fetal reactivity, fetal breathing movements, fetal body
movement, fetal tone, and amniotic fluid volume) into
one assessment.
Biophysical profiles may be done as often as daily during
a high-risk pregnancy. The fetal scores are as follows:
• A score of 8 to 10 means the fetus is considered to
be doing well.
• A score of 6 is considered suspicious.
• A score of 4 denotes a fetus potentially in jeopardy.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is yet another way to
assess a growing fetus.
Maternal Serum
Maternal serum analysis can reveal information about
the pregnant woman as well as the fetus.
Maternal Serum α-Fetoprotein AFP
is a substance produced by the fetal liver that can be
found in both amniotic fluid and maternal serum
(maternal serum α-fetoprotein
[MSAFP]).
Maternal Serum for Pregnancy-Associated Plasma
Protein
A Pregnancy-associated plasma protein A (PAPP-A) is a
protein secreted by the placenta; low levels in maternal
blood are associated with fetal chromosomal anomalies,
including trisomies 13, 18, and 21 or small-for-
gestational-age (SGA) babies.
Quadruple Screening
Quadruple screening analyzes four indicators of fetal
health: AFP, unconjugated estriol (UE; an enzyme
produced by the placenta that estimates general well-
being), hCG (also produced by the placenta), and inhibin
A (a protein produced by the placenta and corpus
luteum associated with Down syndrome)
Fetal Gender
This early diagnosis could be helpful to a woman who
has an X-carrying genetic disorder so she could discover
if she has a male fetus who could inherit the disease or
a female fetus who will be disease-free
INVASIVE FETAL TESTING
Percutaneous umbilical blood sampling
(PUBS; also called cordocentesis or funicentesis) is the
aspiration of blood from the umbilical vein for analysis.
Fetoscopy
This method allows direct visualization of both the
amniotic fluid and the fetus
Women With Unique Needs or Concerns
• morbidly obese woman
• Women who are wheelchair
• women who are hearing challenged
• Women who are blind
Effects of Teratogens on the fetus:
Teratogen
is any factor, chemical or physical, that adversely affects
the fertilized ovum, embryo, or fetus.
Effects of Teratogens on a Fetus Several factors
1. The strength of the teratogen (For example,
radiation is a known teratogen.
In small amounts (everyone is exposed to some
radiation every day, such as from sun rays), it causes no
damage. In large doses (e.g., the amount of radiation
necessary to treat cancer of the cervix), serious fetal
defects or death can occur.
2. The timing of the teratogenic insult makes a
significant impact on damage done to the fetus

3. Determining the effects of a teratogen is the
teratogen’s affinity for specific tissue.
• Lead and mercury, for example, attack and
disable nervous tissue
• Thalidomide, a drug once used to relieve nausea
in pregnancy, causes limb defects.
• Tetracycline, a common antibiotic, causes tooth
enamel deficiencies and, possibly, long-bone
deformities.
• The rubella virus can affect many organs: the
eyes, ears, heart, and brain are the four most
commonly attacked.
Teratogenic Maternal Infections
Several diseases that are commonly known to cross the
placenta and cause fetal harm are tested for and are
described collectively under the umbrella term TORCH,
an abbreviation for toxoplasmosis, others (HIV, hepatitis
viruses, varicella, parvovirus) rubella, cytomegalovirus,
and herpes simplex virus, syphilis
What Is a TORCH Screen?
A TORCH screen is a panel of tests for detecting
infections in
pregnant women. Infections may be passed on to a
fetus during
pregnancy. Early detection and treatment of an infection
can prevent complications in newborns.
Toxoplasmosis
• a protozoan infection, is spread most commonly
through contact with uncooked meat, although it
may also be contracted through handling cat stool in
soil or cat litter
• A woman experiences almost no symptoms of
the disease except for a few days of malaise and
posterior cervical lymphadenopathy.
• mild symptoms, if the infection crosses the
placenta, the infant may be born with central
nervous system damage, hydrocephalus,
microcephaly, intracerebral calcification, and retinal
deformities.
Rubella virus
 usually causes only a mild rash and mild systemic
illness in a woman, but the teratogenic effects on a
fetus can be devastating
 Fetal damage from maternal infection with rubella
(German measles) includes hearing impairment,
cognitive and motor challenges, cataracts, cardiac
defects (most commonly patent ductus arteriosus
and pulmonary stenosis), intrauterine growth
restriction (IUGR), thrombocytopenic purpura, and
dental and facial clefts, such as cleft lip and palate.
Cytomegalovirus (CMV)
• a member of the herpes virus family, is another
teratogen that can cause extensive damage to a
fetus while causing few symptoms in a woman
• It is transmitted from person to person by
droplet infection such as occurs with sneezing.
• If a woman acquires a primary CMV infection
during pregnancy and the virus crosses the
placenta, the infant may be born severely
neurologically challenged (hydrocephalus,
microcephaly, spasticity) or with eye damage (optic
atrophy, chorioretinitis), hearing impairment, or
chronic liver disease.
• The child’s skin may be covered with large
petechiae (“blueberry-muffin” lesions).
Herpes Simplex Virus (Genital Herpes Infection)
 The first time a woman contracts a genital herpes
infection, systemic involvement occurs.
 The virus spreads into the bloodstream (viremia)
and crosses the placenta to a fetus posing
substantial fetal risk If the infection takes place in
the first trimester, severe congenital anomalies or
spontaneous miscarriage may occur.
 If the infection occurs during the second or third
trimester, there is a high incidence of premature
birth, intrauterine growth restriction, and
continuing infection of the newborn at birth.
Other viral diseases:
Syphilis
• a sexually transmitted infection, is of great concern
for the maternal–fetal population despite the
availability of accurate screening tests and proven
medical treatment, as it is growing in incidence and
places a fetus at risk for intrauterine or congenital
syphilis
• Early in pregnancy, when the cytotrophoblast
layer of the chorionic villi is still intact, the causative
spirochete of syphilis, Treponema pallidum, cannot
cross the placenta and damage the fetus.
Lyme disease
• a multisystem disease caused by the spirochete
Borrelia burgdorferi, is spread by the bite of a deer
tick.
• The highest incidence occurs in the summer and
early fall.
 • The largest outbreaks of the disease are found
on the east coast of the United States
• After a tick bite, a typical skin rash, erythema
chronicum migrans (large, macular lesions with a
clear center), develops.
• Pain in large joints such as the knee may
develop. Infection in pregnancy can result in
spontaneous miscarriage or severe congenital
anomalies.
Infections That Cause Illness at Birth:
• Several infections are not teratogenic to a fetus
during pregnancy but are harmful if they are
present at the time of birth.
• Gonorrhea, candidiasis, Chlamydia, Streptococcus B,
and hepatitis B infections are examples of these.
Potentially Teratogenic Vaccines
 Live virus vaccines, such as measles, HPV, mumps,
rubella, and poliomyelitis (Sabin type), are
contraindicated during pregnancy because they may
transmit the viral infection
 Care must be taken in routine immunization
programs to make sure that adolescents about to be
vaccinated are not pregnant.
 Women who work in biologic laboratories where
vaccines are manufactured are well advised not to
work with live virus products during pregnancy.
Teratogenic Drugs
Two principles always govern drug intake during
pregnancy:
I. Any drug or herbal supplement, under certain
circumstances, may be detrimental to fetal welfare.
Therefore, during pregnancy, women should not
take any drug or supplement not specifically
prescribed or approved by their physician or nurse-
midwife.
II. A woman of childbearing age and ability should not
take any drug other than one prescribed by a
physician or nurse-midwife to avoid exposure to a
drug should she become pregnant.
Teratogenicity of Alcohol
 Evidence over the years has shown that when
women consume a large quantity of alcohol during
pregnancy, their babies show a high incidence of
congenital deformities and cognitive impairment.
 The large buildup of this leads to vitamin B
deficiency and accompanying neurologic damage.
 The infant typically has a characteristic
craniofacial deformity including short palpebral
fissures, a thin upper lip, and an upturned nose.
Teratogenicity of Cigarettes
• Cigarette smoking is associated with infertility in
women.
• Cigarette smoking by a pregnant woman has been
shown to cause fetal growth restriction
• In addition, a fetus may be at greater risk for being
stillborn and, after birth, may be at greater risk than
others for sudden infant death syndrome.
• Low birth weight in infants of smoking mothers
results from vasoconstriction of the uterine vessels,
an effect of nicotine.
Environmental Teratogens
• Teratogens from environmental sources can be
as damaging to a fetus as those that are directly
or deliberately ingested.
• Women can be exposed through contact at
home or at work sites.
• For example, washing children’s hair with a
shampoo such as lindane (Kwell) to remove lice
should be limited to two exposures because of
potential toxicity
Radiation
Rapidly growing cells are extremely vulnerable to
destruction by radiation. That makes radiation a potent
teratogen to unborn children because of their high
proportion of rapidly growing cells.
Hyperthermia and Hypothermia
 Hyperthermia to a fetus can be detrimental to
growth because it interferes with cell metabolism.
 This can occur from the use of saunas, hot tubs, or
tanning beds, from a work environment next to a
furnace, such as in welding or steel making.
 The effect of hypothermia on pregnancy is not well
known.
 Because the uterus is an internal organ, a woman’s
body temperature would have to be lowered
significantly before a great deal of fetal temperature
change would result.
Teratogenic Maternal Stress
Many myths exist about the effect of being frightened - measures maturity of fetal lung
or surprised while pregnant. - the protein component of the enzyme surfactant
- Normal Ratio 2:1
For example:
- If a woman sees a mouse during pregnancy, her Alpha-Feto Protein
child will be born with a furry or molelike birthmark. - major plasma of early fetus
- Eating strawberries causes strawberry birthmarks. - decrease after 13 weeks of gestation
- Looking at a handicapped child while pregnant will - with AFP: neural tube defect
cause a child in utero to be handicapped the same
way. OXYTOCIN CHALLENGE TEST (OCT) / CONTRACTIONS
STRESS TEST (CST)
LABORATORY TESTS: - done for evaluation of the ability of the fetus to
withstand the stress of uterine contractions
1. Blood grouping - determine the blood type
2. Hgb/Hct - to detect anemia, Hgb < 11 g/dl or Hct < Indication: If the woman has a non-reactive non-stress
32% requires iron supplementation test
3. CBC - to detect infection or cell abnormalities Procedure: Diluted IV Oxytocin is given via infusion
4. Rh factor - for possible maternal-fetal blood pump
incompatibility
5. VDRL or RPR (Rapid Plasma Reagin) - serologic test Interpretation:
for syphilis Negative:
6. Urinalysis - 3 contractions in 10 min (No Late Deceleration)
7. Antibody titers for rubella & Hepatitis B Positive:
8. HIV Screening - presence of Late Deceleration in response to uterine
9. Glucose Tolerance test contractions (Indicates Placental Insufficency)
10. Tuberculosis Screening
HEALTH EDUCATION:
Schedule of Pre- visits up to 32 weeks
• once/ 2 months 1. Use effectively the knowledge gained in the
• 32- 36 weeks – 2x / months discussion of prenatal care.
• 36 weeks to delivery- once a week 2. Identify health problems, discomforts and
needs of pregnant mothers.
Leopold’s maneuver 3. Enumerate the different prenatal exercises.
 a systematic way of observation & palpation to 4. Formulate the plan of action in taking care of
determine fetal position prepartum clients
5. Discuss possible danger S/S of pregnancy,
Assessment of Fetal Well-being & Maturity during the course of labor, delivery and its nursing
interventions.
 done during the 26th week of gestation 6. Explain factors affecting the normal process of
labor and delivery.
Amniocentesis 7. Show behaviors of concern, compassion and
 early 1st trimester: competence in the care of prepartum and
- to detect congenital abnormalities intrapartum mothers and family

 3rd trimester: 1) Weight gain

- determine fetal lung maturity Normal weight
2-5 lbs – 1st trimester
Post amniocentesis 1 lb/week – 2nd & 3rd trimester
- Let the mother drink 2-4 glasses of water within 2 Total Weight Gain: 25-35 lbs
hours
- Monitor vital signs
Components of Weight Gain:
Lecithin/Sphingomyelin (L/S) Ratio  Fetus - 7.5 lbs
 Placenta - 1-1.5 lbs Mgt:
 Amniotic Fluid - 2 lbs - avoid constricting clothing
 Uterus - 2.5 lbs - avoid crossing legs at the knees
 Breast tissue - 3 lbs - frequent rest periods with legs elevated
 Blood Volume - 4 lbs - wear support ( elastic stockings
 Maternal stores - 4-8 lbs___ - Keep within the recommended weight gain
24 – 28 lbs - avoid prolong standing (change position frequently if
standing )
2) Nutrition
Calories– increase 300 Kcal/day • Hemorrhoids
CHON– 4 servings of meat recommended or 60 - due to smooth muscle relaxation effect of
g/day progesterone constipation and pressure of the
Ca – 1200 mg/day gravid uterus
Folate – 0.4 mg/day Mgt:
Iron – 30 mg/day - hot sitz bath
- Avoid constipation
3) Rest - Rest/ sleep in sim’s position
• encourage mother to sit down & elevate the feet - Avoid long standing or walking
• 10 hours of sleep - Topical anesthetic agents as prescribed
• modified Sim’s
• Leg cramps
4) Exercise - caused by imbalance of Ca & phosphorus
• amount & type of exercise depend on the physical Mgt:
condition of the woman & stage of pregnancy - to relieve cramps, extend the affected leg, keeping
a. Walking knees straight, bend your foot toward you /or ask
- most ideal exercise because it stimulates muscular someone to help you flex your foot.
activity of the entire body & does not result in fatigue or - diet rich in calcium, phosphorous
strain. - B- complex supplement.
b. Kegels exercise
- aid in restoration of perineal muscles & prevent stress • Frequent urination
incontinence - due to pressure of the gravid uterus on the bladder
Mgt:
Tailor sitting - will be resolved without intervention. However, you
- for relief of backache can use Kegel’s exercise to lessen the discomfort
- stretches perineal muscles - void every 2hrs/ or as necessary
- avoid caffeine
Pelvic tilt • Backache
– for relief of backache - caused by the enlarging uterus/ lordosis
Mgt:
Shoulder circling - tailor sitting
– for relief of backache - shoulder circling
- pelvic rock
5) Sexual Relations - squat rather than bend when lifting
- no restrictions
- CI: vaginal bleeding, ruptured membranes • Leukorrhea
- strong uterine contraction after orgasm - profuse whitish vaginal discharge
Mgt:
COMMON DISCOMFORTS OF PREGNANCY - wear perineal pads
- clean perineal area always (front to back)
• Varicosities - wear cotton underwear
- due to pressure of the gravid uterus to the large
veins • Hypotension
- caused compression of inferior vena cava
Mgt:
- Left side lying position
- move/ rise up slowly

• Dyspnea
- difficulty of breathing
Mgt:
- elevate head of bed
- Avoid having a full stomach
- avoid physical exertion

• Ankle edema
- reduced blood circulation in lower extremities
Mgt:
- avoid constricting clothing
- open, flat footwear
- elevate leg while resting
- avoid long standing or walking

• Pica
- compulsion of craving food
- assoc. with Iron Deficiency Anemia
Mgt:
- iron supplements
- Small, frequent meals

DANGER SIGNS OF PREGNANCY

1. vaginal spotting/bleeding
2. leaking of fluid from the vagina
3. unusual abdominal cramps
•1st trimester- ectopic pregnancy
• 3rd trimester- abruption placenta
4. persistent headache, blurring of vision
5. marked swelling of hands & feet
6. painful, burning urination discharge
7. foul smelling vaginal discharge
8. chills & fever
9. persistent nausea & vomiting