CARE OF MOTHER, CHILD, and ADOLESCENT

NCM 107

ANTEPARTUM / PREGNANCY
TOPIC 11-15

MODULE 2

ESPIRITU, GIZZI ASBELLE P.

BSN 2102
 TABLE OF CONTENTS

11. Normal Diagnostic/ Laboratory Findings & Deviations

12. Appropriate Nursing Diagnoses
13. Addressing the Needs and Discomfort of Pregnant Mothers
14. Prenatal Exercises
15. Preparation for Labor and Delivery
LEARNING OBJECTIVES:

 To recall the anatomy and physiology of female

reproductive system.
 To be familiar with the normal diagnostic/laboratory
findings and deviations.
 To be informed what are the needs and discomforts of
pregnant mothers.
 Preparedness for prenatal exercises.
 Determine the preparations for labor and delivery.
 NORMAL LABORATORY FINDINGS AND DEVIATIONS

FETAL MOVEMENT
 It can be felt by the mother (quickening) occurs at
approximately 18 to 20 weeks of pregnancy and peaks intensity
at 28 to 38 weeks.

a) 18 – 20 wks – quickening felt by mother.

b) 28 – 38 wks – 10x /hr. peaks in intensity.

 A healthy fetus moves with a degree of consistency, or at least

10 times a day. In contrast, a fetus not receiving enough
nutrients because of placental insufficiency has greatly
decreased movements.
 Based on this, asking a woman to observe and record the
number of movements the fetus is making offers a gross
assessment of fetal well-being.

SANDOVSKY METHOD

 One way to approach this assessment is to ask the woman to

lie in a left recumbent position after a meal and record how
many fetal movements she feels over the next hour.
 In this position, a fetus normally moves a minimum of twice
every 10 minutes or an average of 10-12 times n hour. If less
than 10 movements occur within an hour, the woman repeats
the test for the next hour. She should call her health care
provider if she feels fewer than 10 movements.

CARDIFF METHOD

 Another protocol is “Count-to-Ten”. For this, a woman records

the time interval it takes for her to feel 10 fetal movements.
Usually, this occurs within 60 minutes.
 Fetal movements do vary, especially in relation to sleep cycles
of fetus, her activity, and the time since she last ate. Otherwise,
women might get worried that her fetus may be in jeopardy
when the fetus is just having an inactive time.
 FETAL HEART RATE
 Fetal heart beat at 120 to 160
beats per minute throughout
pregnancy.
 Fetal heart sounds can be heard
and counted as early as the 10th
to 11th week of pregnancy by the
use of an ultrasonic Doppler
technique.
NON-STRESS TEST
 In a non-stress testing, the
response of the fetal heart rate
is measured in response to the
fetal movement.
 The woman is attached to a
fetal heart rate and uterine
contraction monitor.
 The woman should push the
button of the monitor whenever
she feels the fetus move.
 Normally, when the fetus
moves, the fetal heart should
increase for about 15 beats per
minute and remain elevated for
15 seconds.
 The normal FHR tracing include
baseline rate between 110-160
beats per minute (BPM),
presence of accelerations and
no decelerations.
 A baseline heart rate greater
than 160 BPM is defined as
tachycardia and is considered a
non-reassuring pattern.
 The non-stress test is done for
10 to 20 minutes.
 The result is reactive if there are
two accelerations of fetal heart
rate lasting for 15 seconds that
occurs after movement.
 The result is non-reactive if there
are no fetal accelerations after a
fetal movement, or there is no
fetal movement.
 If the non-stress test ins
noncreative, a contraction stress
test or biophysical profile will be
scheduled.
 FETAL HEART RATE
(CONTRACTION STRESS TESTING)

 A contraction sires test checks to see if your baby will stay

healthy during contractions when you are in labor.
 This test includes external fetal heart monitoring. The test is
done when you are 34 or more weeks pregnant.
 During a contraction, the blood and oxygen supply to your baby
drops for a short time.
 If your baby’s heart rate drops during contractions, it could be a
sign of problems. Your doctor may suggest further testing.
Sometimes, early delivery is the best option.
 If your baby’s heal rate stays normal during the test, that’s an
excellent sign. Still, your doctor may suggest that you take the
test again later if other test results show a possible problem.

ULTRASONOGRAPHY

 Ultrasonography measures the response of sound waves against

solid objects.
 It can diagnose a pregnancy of 6 weeks of gestation, confirm the
presence, size, and location of the placenta, establish that the
fetus is growing , detect any gross anomalies, establish the fetal
sex, and determine the presentation and position of the fetus.
 The woman has to have a full bladder at the time of the
procedure.
 Have the woman drink a full glass of water every 15 minutes to 90
minutes before the procedure until the start of the procedure.
MATERNAL SERUM ALPHA FETOPROTEIN

 AFP is found in the amniotic fluid and the maternal serum and is
produced by the fetal liver.
 MSAFP levels start to increase at 11 weeks gestation and
increases steadily until term.
 The MSAFP level is abnormally high if there is spina bifida defect
or abdominal defect.
 The MSAFP level is low if the fetus has a chromosomal defect
such as Down syndrome.
 The MSAFP is assessed at the 1st week of pregnancy and can
detect 8S% to 90% of neural tube defects and 8o% of Down
syndrome.

CHORIONIC VILLI SAMPLING

 The test is highly accurate and yields no more false-positive results

than does amniocentesis.
 Although this procedure may be done as early as week 5 of
pregnancy, it is more commonly done at 8 to 10 weeks.
 With this technique, the chorion cells are located by ultrasound

AMNIOCENTESIS

 Amniocentesis is the aspiration of amniotic fluid from the

pregnant uterus for examination.
 The test is typically done between the 14th and 16th weeks of
pregnancy so that there is a generous amount of amniotic fluid
present.
 Before the procedure, instruct the woman to void, and then
place her on a supine position.
 Fetal heart rate and uterine contraction monitors are attached
to the woman, and blood pressure and fetal heart rate are
taken.
 Inform the woman that she might feel pressure as the needle is
introduced, but do not advise her to take a deep breath and
hold it in.
 About 15 mL of amniotic fluid is aspirated.
 Amniotic fluid is analyzed for AFP, bilirubin determination,
chromosome analysis, color, fetal fibronectin, inborn errors of
metabolism, lecithin-sphingomyelin ratio, and
phosphatidylglycerol and desaturated phosphatidylcholine.
 PERCUTANEOUS UMBILICAL
BLOOD SAMPLING

 PUBS, or cordocentesis, is the removal of blood from the fetal umbilical cord at about 17
weeks using an amniocentesis technique
 This allows analysis of blood components aswell as more rapid karyotyping than is possible
when only skin cells are removed.

BIOPHYSICAL PROFILE

 The biophysical profile combines five parameters into one assessment.

 Fetal heart rate and breathing measure short-term central nervous system function.
 The amniotic fluid volume measures long-term adequacy of placental function.
 The biophysical profile is more accurate than any other single assessment method.
 The score ranges from 2-10, with 10 as the highest.
 If the fetus has a score of 8 to 10, it is doing well.
 If the score is 6, this is considered suspicious.
 A score of 4 denotes that fetus might be in jeopardy.
 The assessment is similar to that of an Apgar scoring, and it is commonly called as fetal Apgar.

APPROPRIATE NURSING DIAGNOSE

 Addressing the Needs and Discomfort of
Pregnant Mothers

 Kergel's position for constipated pregnant women.

 A “feet-up” break during a workday helps prevent fatigue.

 Relieving a leg cramp in
pregnancy.

 Position to relieve varicosities

 Position to relieve varicosities

 Physiological and Psychological Changes in Pregnancy

DIAGNOSIS OF PREGNANCY

Presumptive Signs of Pregnancy:

 Subjective (experienced by a woman) - breast changes, nausea, vomiting,

amenorrhea,
frequent urination, fatigue, uterine enlargement, quickening, linea negra,
melasma, stria gravidarum.

Probable Signs of Pregnancy:

 HCG in urine or blood serum of a woman

 Accurate 95% or 98% of the time
 Home pregnancy tests are 97% accurate
 Women taking psychotropic drugs may have a false positive result on pregnancy
test
 Discontinued oral contraceptives 5 days before the test
 Chadwick's sign
 Goodell's sign
 Hegar's sign
 Sonographic evidence of gestational sac
 Ballottement
 Braxton hicks sign
 Fetal outline Felt by examiner

Positive Signs of Pregnancy:

 Sonographic evidence of fetal outline

week 6-8
 Fetal heart audible
week 18-20
 Fetal movement Felt by examiner
week 20-24
Psychological Changes of Pregnancy:

 Social influences
 Cultural influences
 Family influences
 Individual influences

Psychological Stages of Pregnancy:

1st trimester: Accepting the pregnancy

 Impaired memory
 Emotional liability
 Preoccupation with bodily needs (especially
food)
 Focus on secrecy/privacy of the knowledge
of pregnancy.

2nd trimester: Accepting the baby

 Emotional attachment to fetus
 Recognizing fetus as separate individual
 Decrease in uncomfortable physical
symptoms -> relative calm
 Increase in signs of nurturing, such as talking
to fetus
 Increase in anxiety about mothering, and
identifying with own mother
 With increasing awareness of fetus as
separate entity, new feelings of ambivalence,
resentment
 As pregnancy begins to show, loss of control
over who know.

3rd trimester: Accepting the baby

 Maternal-fetal attachment peaks, and at the
same time, mother prepares for separation
(delivery)
 preparation for baby: nesting behaviors
 somatic concerns and physical discomfort
 worries about delivery
 Baby’s health
 REPRODUCTIVE SYSTEM

Uterine Changes

 Length increases from approximately 6.5 to 32 cm.

 Depth increases from 2.5 to 22 cm.
 Width expands from 4 to 24 cm.
 Weight increases from 50 to 1000 g.
 Early in pregnancy, the uterine wall thickens from about 1 cm to about 2 cm; toward the end of
pregnancy, the wall thins to become supple and only about 0.5 cm thick.
 The volume of the uterus increases from about 2 mL to more than 1000 mL. The uterus can
hold a 7-lb (3175-g) fetus plus 1000 mL of amniotic fluid for a total of about 4000 g at term.
 Uterine growth is due to formation of a few muscle fibers and stretching of existing muscle
fibers
 Week 12 the fetus is palpated just above
the symphysis pubis Week 20 to 22 the
fetus is at the umbilicus
 Week 36 should touch the xiphoid process.

Psychological Changes of Pregnancy

 Hegar's sign
 This is the softening of the lower uterine segment just above the cervix.
 Ballottement
 On bimanual exam, tapping of lower segment the fetus is felt to bounce or rise in the
amniotic fluid up against the top examining hand.
 Cervical changes
 Cervix is more vascular and edematous
 Increased fluid between the cell causes the cervix to softened and increase
vascularity causes it to darken from pale pink to a violet hue
 A tenacious coating of mucus fills the cervical canal
 Operculum
 A mucus plug that acts to seal out bacteria during
pregnancy and therefore helps prevent infection in the fetus and membranes.

 Goodell's sign
Softening of the cervix indicative of pregnancy appearing around six weeks into gestation.
 Nonpregnant cervix is like the nose
 Pregnant is like earlobe
 Vaginal changes
 Vaginal epithelium become hypertrophic and enriched with glycogen which results
in white vaginal discharge throughout pregnancy.
 Chadwick's sign
 Vaginal walls are deep violet color due to increased circulation.
 Ph 4 to 5 favors growth of candida albicans (yeast like fungi).

 Ovarian changes
Ovulation stops
Corpus luteum increases in size until week 16 and then the
placenta has taken over as provider of progesterone and
estrogen.
 Changes in the breasts
 Feeling of fullness, tingling or tenderness
 Size increases due to hyperplasia of mammary alveoli and fats deposits
 Areola darkens and diameter increases to 1 1/2 to 3 inches
 Blue veins become prominent
 Montgomery's tubercules - sebacious glands of the areola enlarge and become
protuberant.
 Secretions keep the nipple supple and help prevent cracking and drying during
lactation
 Week 16 colostrum - a thin, watery, high protein fluid canbe expelled from the
breasts.
 Integumentary system
 Striae gravidarum --- pink or reddish streaks on sides of abdomen and thighs
caused by rupture and atrophy of the connective later of the skin. After birth this
lightens to silvery-white color.
  Diastasis --- means separation, rectus muscles seperate,
will appear after pregnancy as a bluish groove.
 Umbilicus stretches until it is smooth.
 Extra pigmentation on abdominal wall

 Linea Nigra --- brown line from umbilicus to symphysis pubis.

 Melasma --- darkened areas on face due to melanocytes, stimulating hormones

secreted by the pituitary.
  Vascular spiders --- small fiery-red branching spots on thighs, increase estrogen.

 Respiratory system
 Shortness of breath
 Diaphragm is displaced by 4cm upward
 Mild hyperventilation
 Polyuria - increased urination due to plasma bicarbonate excreted by the kidneys
 Respirations > 20/min
 Congestion of nasopharynx - increased estrogen level
 Cardiovascular system
Blood volume
 Increases by 30 to 50%
 Blood loss at birth - 300 to 400 ml
 Systemic changes
Blood volume
 Increases by 30 to 50%
 Blood loss at birth - 300 to 400 ml
 Gastrointestinal system
 Gum hyperatophy
 saliva production
 nausea, vomiting and heartburn
 encouraged pregnant woman to sit up for 30 minutes before lying down,
 constipation
 Skeletal system
 Waddling gait (slight separation of symphesis pubis) as a result of pressure effect of
the fetus.
 The center lordosis backache.
 PRENATAL EXERCISE

PHYSICAL EXERCISE FOR

PREGNANT WOMEN

 Regular exercise during pregnancy can improve posture and decrease some common
discomforts such as backaches and fatigue.
 There is evidence that physical activity may prevent gestational diabetes, relieve stress, and
build more stamina needed for labor and delivery.
 Moderate, low impact aerobic exercise are encouraged instead of high impact.
 Regular exercise during pregnancy can improve posture and decrease some common
discomforts such as backaches and fatigue.
 There is evidence that physical activity may prevent gestational diabetes, relieve stress, and
build more stamina needed for labor and delivery.
 Moderate, low impact aerobic exercise are encouraged instead of high impact.

WHO SHOULD NOT EXERCISE

DURING PREGNANCY

 Exercise is not advisable to pregnant women who has a medical

problem such as asthma, heart disease, or diabetes.
 Exercise may also be harmful if they have a pregnancy related
condition as:
 Bleeding
 Weak cervix
 Low placenta
 Threatened or recurrent miscarriage
 Previous premature births or history of early labor.
 WHO MAY EXERCISE
DURING PREGNANCY

 A pregnant woman is eligible to participate in physical exercises if she does not have any
medical complications.

THINGS TO REMEMBER:

 Women should avoid exercise that involves the risk of abdominal trauma, falls, or excessive
joint stress combat sports, racquet sports, contact sports, extreme sports.
 Adequate hydration and proper ventilation are important to prevent possible effects of
overheating.

JOGGING
 In contrast, is questioned because of the strain that the extra weight of pregnancy
places on the knees. Late in pregnancy, jogging can cause pelvic pain from
relaxed symphysis pubis movement.

WALKING
 It is considered as one of the best cardiovascular exercises for pregnant women.
 Walking is the best exercise during pregnancy, and women should be
encouraged to take a walk daily unless inclement weather, many levels of stairs,
or an unsafe neighborhood are contraindications

SWIMMING AND WATER WORKOUTS

 The water supports the weight of your growing baby and moving against the
water helps keep your heart rate up. It’s also easy on your joints and muscles. If
you have low back pain when you do other activities, try swimming.
RIDING A STATIONARY BIKE
 This is safer than riding a regular bicycle during pregnancy. You’re less likely to
fall off a stationary bike than a regular bike, even as your belly grows.

YOGA and PILATES CLASSES

 This is safer than riding a regular bicycle during pregnancy. You’re less likely to
fall off a stationary bike than a regular bike, even as your belly grows.

LOW-IMPACT AEROBICS CLASSES

 During low-impact aerobics, you always have one foot on the ground or
equipment. Examples of low-impact aerobics include walking, riding a stationary
bike and using an elliptical machine. Low-impact aerobics don’t put as much
strain on your body that high-impact aerobics do. During high-impact aerobics,
both feet leave the ground at the same time. Examples include running, jumping
rope and doing jumping jacks. Tell your instructor that you’re pregnant so that
they can help you modify your workout, if needed.

STRENGTH TRAINING
 Strength training can help you build muscle and make your bones strong. It’s
safe to work out with weights as long as they’re not too heavy. Ask your provider
about how much you can lift.
HEALTH PROMOTION DURING PREGNANCY

BATHING

 During pregnancy, sweating tends to increase because a woman excretes waste products for
herself and a fetus.
 She also has an increase in vaginal discharge. For these reasons, daily tub baths or showers
are now recommended.
 As pregnancy advances, a woman may have difficulty maintaining her balance when getting in
and out of a bathtub. If so, she should change to showering or sponge bathing for her own
safety.
CONTRADICTION:

 If membranes rupture or vaginal bleeding is present, tub baths are contraindicated because
then there might be a danger of contamination of uterine contents.
 During the last month of pregnancy, when the cervix may begin to dilate, some health care
providers restrict tub bathing for the same reason.

BREAST CANCER

 A few precautions during pregnancy are helpful to prevent

breast discomfort.
 A general rule is for a woman to wear a firm, supportive bra
with wide straps to spread breast weight across the
shoulders.
 A woman may need to buy a larger bra halfway through
pregnancy to accommodate her increasing breast size.
 If she plans on breastfeeding her newborn, she might
choose bras suitable for breastfeeding so she can continue
to use them after the baby’s birth

CONTRADICTION:

 At about the 16th week of pregnancy, colostrum secretion

begins in the breasts. The sensation of a fluid discharge
from the breasts can be frightening unless a woman is
cautioned that this is a possibility.
 Teach her to wash her breasts with clear tap water (no soap,
because that could be drying and cause nipples to crack)
daily to remove the colostrum and reduce the risk of
infection. Afterward, she should dry her nipples well by
patting them with a soft towel.
 IMMUNIZATION

 Certain vaccines are safe and recommended for women before, during, and after pregnancy to
help keep them and their babies healthy.
 The antibodies mothers develop in response to these vaccines not only protect them, but also
cross the placenta and help protect their babies from serious diseases early in life.
 Vaccinating during pregnancy also helps protect a mother from getting a serious disease and
then giving it to her newborn.
 Some vaccines are not recommended during pregnancy, such as:

CONTRADICTION:
 Human papillomavirus (HPV) vaccine
 Measles, mumps, and rubella (MMR) vaccine
 Live influenza vaccine (nasal flu vaccine)
 Varicella (chicken pox) vaccine
 Certain travel vaccines: yellow fever, typhoid fever, and Japanese encephalitis

SEXUAL ACTIVITY

 Some women are embarrassed to ask questions about sexual relations during pregnancy.
However, most women are concerned about whether sexual intercourse should be restricted.
 Many need information to refute some of the myths about sexual relations in pregnancy that
still exist, such as:
 Coitus on the expected date of her period will initiate labor.
 Orgasm will initiate preterm labor, but participating in sexual relations without orgasm
will not.
 Coitus during the fertile days of a cycle will cause a second pregnancy or twins.
 Coitus might cause rupture of the membranes.
 None of the above are true. Asking a woman at a prenatal visit if she has any questions
about sexual activity allows her to voice such concerns.
 By dispelling these myths, you allow a woman to feel more comfortable and secure that
coitus is not harming her child. There are a few situations when sexual relations during
a pregnancy are contraindicated.

CONTRADICTION:

 Women with a history of spontaneous miscarriage may be advised to avoid coitus during the
time of the pregnancy when a previous miscarriage occurred.
 Women whose membranes have ruptured or who have vaginal spotting should be advised
against coitus until examined to prevent possible infection.
 ACTIVITY 1.3
A. Choose the letter which represents the best answer.

1. It can be felt by the mother (quickening) occurs at approximately 18 to 20 weeks of pregnancy

and peaks intensity at 28 to 38 weeks.
a. Fetal Heart Rate c. Non-Stress Test
b. Fetal Movement d. Ultrasonography
2. This test checks to see if your baby will stay healthy during contractions when you are in
labor.
a. Fetal Heart Rate c. Ultrasonograhy
b. Non-stress Test d. Contraction Stress Test
3. Also known as “Count-to-Ten” method.

a. Cardiff Method c. Chronic Villi Sampling

b. Sandovsky Method d. Precutaneous Umbilical Blood Sampling
4. This allows analysis of blood components as well as more rapid karyotyping than is possible
when only skin cells are removed.
a. Cardiff Method c. Chronic Villi Sampling
b. Sandovsky Method d. Precutaneous Umbilical Blood Sampling
5. The aspiration of amniotic fluid from the pregnant uterus for examination.

a. Ultrasonography c. Non-stress Test

b. Amniocentesis d. Precutaneous Umbilical Blood Sampling
B. Identify the correct answers.

1. This is the softening of the lower uterine segment just above the cervix.
__________________

2. Pink or reddish streaks on sides of abdomen and thighs caused by rupture and atrophy
of the connective later of the skin. After birth this lightens to silvery-white color.
___________________

3. Cervix is more vascular and edematous.

___________________

4. Vaginal epithelium become hypertrophic and enriched with glycogen which results in
white vaginal discharge throughout pregnancy.
___________________

5. Darkened areas on face due to melanocytes, stimulating hormones secreted by the

pituitary.
____________________

KEY ANSWERS:
A. B.
1. B 1. Hegar’s Sign
2. D 2. Striae Gravidarum
3. A 3. Cervic Changes
4. B 4. Vaginal Changes
5. D 5. Melasma