Prenatal

Care
 Objectives:
1. Describe the areas of health assessment commonly included in prenatal
visits.
2. Assess the health status of a pregnant woman and her family.
3. Formulate nursing diagnoses related to a woman’s health status during
pregnancy.
4. Identify expected outcomes to help ensure a safe pregnancy.
5. Using the nursing process, plan nursing care Implement appropriate
nursing care.
6. Evaluate expected outcomes for the childbearing family to establish
achievement and effectiveness of goals.
7. Integrate knowledge of pregnancy health assessment with the interplay
of nursing process
 Health Assessment during
Prenatal Visits

 Schedule of Prenatal Visits:

 Up to 28th week of pregnancy
➢ Every 4 weeks
 28th – 36th week of pregnancy
➢ Every 2 weeks
 36th week until Birth
➢ Every week
 Purpose of Prenatal Care
1. Establish a baseline of present health.
2. Determine the gestational age of the fetus
3. Monitor the fetal development and maternal well-being
4. Identify women at risk for complications
5. Minimize the risk of possible complications by
anticipating and preventing problems before they
occur.
6. Provide time for education about pregnancy, lactation,
and NB care
I. Initial Interview

1. Purposes:

1) Establishing rapport
2) Gaining information about a woman’s physical and
psychosocial health
3) Obtaining a basis for anticipatory guidance for the
pregnancy
 Components of Health History

1. Demographic Data
 Name, age, address, tel. no., e-mail address,
religion, and health insurance information
2. Chief Concern
 The reason a woman has come to the health
care setting (Chief Complaints)
 Inquire about the date of her LMP.
 Elicit information about the signs of early
pregnancy
Components of Health History

2. Chief Concern (continued . . .)

 Elicit information about:
 signs of early pregnancy
 Discomforts of pregnancy
 Danger signs of pregnancy
 Document if pregnancy was planned
3. Family profile
 Identify important support persons
 Marital status
 Size of apartment or house to talk about the
availability of the baby’s room or space
4. History of past illnesses
1. Past medical history
 Kidney disease, varicosities
 Heart disease, hypertension
 STD, UTI
 Diabetes, Thyroid disease
 Recurrent seizures, Gallbladder disease
 Phenylketonuria, TB
 Asthma
4. History of past illnesses (continued . . .)
2. Childhood diseases
 Chickenpox (varicella)
 Mumps
 Measles (rubeola)
 German measles (rubella)
 Poliomyelitis
3. Ask about HPV (human papillomavirus vaccine)
 Has the potential to prevent cervical CA
4. Ask about allergies
5. Ask about past surgical procedures
5. History of Family Illnesses
 Can help identify potential problems in a woman during
pregnancy or in her infant at birth.
6. Day History/ Social Profile
 Elicit information about:
1) Current nutrition (“24-hr. recall”)
2) Elimination
3) Sleep
4) Recreation
5) Interpersonal interactions
6. Day History/ Social Profile
 Ask about hobbies
▪ Smoking, drinking alcoholic beverages
 Medication history
7. Gynecologic History
 Ask about:
1) Age of menarche
2) Menstrual cycle, including interval, duration, amount
of menstrual flow, and associated discomforts with her
menstruation.
3) Past surgery on the reproductive tract
4) Reproductive planning have been used
5) Sexual history
8. Obstetric History
 Ask about:
 Previous miscarriages or therapeutic abortions
 If woman’s blood type is Rh negative, if she
received Rh immune globulin (RhIG [RhoGam]) after
miscarriages.
➢ Used to prevent Rh- sensitization of an Rh- woman.
 Blood transfusion to establish risk of hep B or HIV
8. Obstetric History
 Determine a woman’s status with respect to
the number of times she has been pregnant,
including the present pregnancy, and the
number of children above the age of
viability she has previously borne.
8. Obstetric History
 Comprehensive system of classifying pregnancy status
G ( gravida ) – total # of pregnancies
P ( para) - number of deliveries that reached
viability , regardless of whether the infant
was born alive
Para broken down into :
T = # of full term infants born at 37 weeks or after
P = # of preterm infants born before 37 weeks
A = # of spontaneous or induced abortions
L = # of living children
M = # of multiple pregnancies
GTPAL Practice Questions

Question 1:
 A 26 year old female is currently 26 weeks pregnant.
She had a miscarriage at 10 weeks gestation five
years ago. She has a three year old who was born
at 39 weeks. What is her GTPAL?
GTPAL Practice Questions

Question 1:
 A 26 year old female is currently 26 weeks pregnant.
She had a miscarriage at 10 weeks gestation five
years ago. She has a three year old who was born
at 39 weeks. What is her GTPAL?

 Answer: G=3, T=1, P=0, A=1, L=1

GTPAL Practice Questions

Question 2:
 A 35 year old female is currently pregnant with twins. She
has 10 year old triplets who were born at 32 weeks
gestation, and 16 years old who was born at 41 week
gestation. Twelve years ago she had a miscarriage at 8
weeks gestation. What is her GTPAL?
GTPAL Practice Questions

Question 2:
 A 35 year old female is currently pregnant with twins. She
has 10 year old triplets who were born at 32 weeks
gestation, and 16 years old who was born at 41 week
gestation. Twelve years ago she had a miscarriage at 8
weeks gestation. What is her GTPAL?

 Answer: G=4, T=1, P=1, A=1, L=4

9. Review of systems (use systematic approach such as
head to toe assessment)
 Head – headache, injury, seizures, dizziness
 Eyes - vision, infection, glaucoma
 Ears - earache, hearing loss
 Nose – epistaxis ( nose bleeds ) , allergy, sinus pain
 Mouth and pharynx – dentures, bleeding of gums
 Neck – stiffness, masses
 Breast – lumps, secretions
 Respiratory system – cough , wheezing
 Cardiovascular system - history of heart murmur, heart disease,
hypertension , had blood transfusion
9. Review of systems (use systematic approach
such as head to toe assessment)
 GITsystem – prepregnancy weight, vomiting, diarrhea,
Constipation, change in bowel habits
 Genitourinary system – UTI , pelvic inflammatory Disease
( PID) , hepatitis, HIV
 Extremities- varicose veins, fracture/dislocation, pain
 Skin – rashes, acne, psoriasis
 Physical Examination

 Ask the woman to void for a clean catch urine

specimen before the exam.
 physical exam includes inspection of major body
systems with emphasis on changes that occur with
pregnancy.

I. Baseline height /weight and vital signs measurement

 To establish baseline for future comparison
II. Measurement of fundal height and Fetal Heart Sounds
 Physical Examination

II. Measurement of fundal height and Fetal Heart

Sounds
 12-14 weeks uterus is palpable over symphysis
pubis
 20-22 weeks uterus is palpable at the umbilicus
 36 weeks xiphoid process
 40 weeks uterus is 4 cm below xiphoid process due
to lightening
 Physical Examination

II. Measurement of fundal height and Fetal Heart Sounds

(continued . . .)
 fetalheart sounds ( 120-160 beats per minute ) can be heard at
10-12 weeks if Doppler is used, but not until 18-20 weeks if regular
stethoscope is used.
III. Pelvic examination
 Pelvis
A bony ring formed by 4 united bones:
1) Two innominate bones (flaring hip)
2) Coccyx
3) Sacrum
 Physical Examination
III. Pelvic examination (continued . . .)
 Each innominate bone is divided into 3 parts:
1) Ilium
 Forms the upper and lateral portion
2) Ischium
 Inferior portion
a) At the lowest portion are the ischial tuberosities
➢ These are important markers to determine lower pelvic
width
b) Ischial spines marks the midpoint of the pelvis
➢ This marker is used to assess the level to which the fetus
has descended into the birth canal during labor.
 Physical Examination
III. Pelvic examination (continued . . .)
3) Pubis
 Anterior portion of the innominate bone
 Symphysis pubis is the junction of the innominate
bones at the front of the pelvis.
 Sacrum
 Forms the upper posterior portion of the pelvic
ring.
 Used as a landmark to identify pelvic
measurements.
 Physical Examination

III. Pelvic examination (continued . . .)

 Coccyx
 Just below the sacrum
 Pelvis
 Divided into:
1) False pelvis (superior half)
2) True pelvis (inferior half)
 Pelvic examination
 revealsinformation on the
health of both internal and
external reproductive organs
 Woman should void to reduce
her bladder size and then lie in
a lithotomy position
1. nulligravida cervix ( woman who is not or never has
been pregnant)
 cervix is round and small
2. woman who has had vaginal birth
 cervical os is like a slitlike appearance
3. woman had cervical tear during previous birth
 the cervical os transverse increase in width or a typical
starlike ( stellate) formation
 Vaginal inspection

 Examination of pelvic organs

▪ early sign of pregnancy ( hegar’s
sign ) can be determined as well
 Estimating pelvic size

 This is to determine whether woman’s pelvic

ring will be adequate for a fetus to pass
through its center.
 Types of woman’s pelvis:
1) Android
 Male pelvis
 Pubic arch in this type of pelvis extremely narrow
 Fetus may have difficulty exiting
 Estimating pelvic size

 Types of woman’s pelvis:

2) Anthropoid
“ ape like pelvis
 Transverse
diameter is narrow and
anteroposterior diameter of the inlet is larger
than normal
 Structure does not accommodate fetal head
 Estimating pelvic size

 Types of woman’s pelvis:

3) Gynecoid
 normal " female pelvis
 inlet
is rounded forward and backward,
pubic arch is wide
 pelvic type is ideal for childbirth
 Estimating pelvic size

 Types of woman’s pelvis:

4) platypelloid
“ flattened pelvis
 Inlet
is an oval , smoothly curved and
anteroposterior diameter is shallow
 Fetal head may not be able to rotate
 Estimating pelvic size

 Internal Pelvic Measurements:

1. Diagonal Conjugate
 Distance between the anterior
surface of the sacral prominence
and the anterior surface of the
inferior margin of the symphysis DIAGONAL
pubis CONJUGATE

 Adequate: 12.5 cm
 Estimating pelvic size

 Internal Pelvic Measurements:

2. True conjugate or Conjugate
Vera
 Measurement between the TRUE
anterior surface of the sacral CONJUGATE

prominence and the posterior

surface of the inferior margin of
the symphysis pubis.
 Average diameter: 10.5 – 11 cm
 Estimating pelvic size

 Internal Pelvic Measurements:

3. Ischial Tuberosity
Distance between the ischial
tuberosities, or the transverse
diameter of the outlet.
Adequate: 11 cm.
 Laboratory Assessment

1. Blood studies
1) CBC
2) Genetic screen = ex. Beta thalassemia
3) Serologic test for syphilis
4) Blood typing including Rh factor
5) MSAFP (done @ 16-18 wks AOG)
6) Indirect Coombs’ test
 Determination if Rh antibodies are present in an Rh- woman.
 If titers not elevated Rh- woman will be given RhIG (RhoGAM) at 28
weeks pregnancy
 Laboratory Assessment

1. Blood studies (continued . . .)

7) Antibody titers for rubella and hepatitis
8) HIV screening
 Screening is done by enzyme-linked immunosorbent assay
(ELISA), if positive…
❖ Western blot
― USED TO IDENTIFY/DETECT SPECIFIC ANTIBODY
 Therapy with zidovudine (AZT) if HIV antibody +
▪ Decrease the risk of infant acquiring the virus
 Laboratory Assessment
9)OGTT (Oral Glucose Tolerance Test)
 Should not exceed 140 mg/dl at 1 hr.
▪ If a woman has a history of previously unexplained fetal loss, has
a family history of diabetes, has had babies who were large for
gestational age (9 lb or more at term), has a BMI over 30, or has
glycosuria
― she will need to be scheduled for a 50-g oral 1-hour glucose loading
or tolerance test (sometimes called a glucose challenge test)
toward the end of the first trimester (12 weeks) to rule out gestational
diabetes.
▪ The addition of a serum Glycosylated hemoglobin(HbA1C) has
the best predictive value for identifying diabetes because it
measures blood glucose level for the past 2-3 months.(Hughes,
Moore, Gullam, et al., 2015).
 Laboratory Assessment
1. Blood studies (continued . . .)
2. Urinalysis
 For proteinuria, glycosuria, pyuria
3. Tuberculosis screening(MANTOUX TEST)
➢ a woman’s primary care provider may prescribe a purified protein
derivative (PPD) tuberculin test for a woman as a test for
tuberculosis.
 Laboratory Assessment
3. Tuberculosis screening(MANTOUX TEST)
➢ For this test, a small amount (0.1 ml) of tuberculin units are injected by
a needle and syringe intradermally (just under the top layer of skin).
➢ In 48 to 72 hours, the area is inspected.
➢ If the woman has tuberculosis, has been exposed to tuberculosis, or
has received the bacille Calmette–Guérin (BCG) vaccine for
tuberculosis
― a reddened, raised, hardened area (called induration) will appear at
the injection site.
➢ If the induration area is at least 10 cm in diameter
― the test is considered positive (a person has been either exposed to
tuberculosis or has tuberculosis);
― in a person with a lowered immune response, 5 cm can be
considered a positive result.
 Laboratory Assessment
4. Ultrasonography
➢ If the date of the last menstrual period is unknown, a woman will be
scheduled for a sonogram to confirm the pregnancy length and
document healthy fetal growth at 7 to 11 weeks of pregnancy.
➢ An ultrasound may also be done, ideally between 11 and 13 weeks of
pregnancy, as a part of a first trimester screening to assess for
increased risk of Down syndrome.
➢ A sonogram can be scheduled between 16 and 20 weeks gestation to
verify healthy fetal structures and gender.
➢ Be certain women know that a sonogram done under 8 weeks will
show only the presence of a gestation sac, not a moving, kicking fetus,
so their expectations of what they will see are not disappointing
(Gonçalves, 2016).
 Complications of Pregnancy
(danger signs)

1. Vaginal bleeding
2. Persistent vomiting
3. Chills and fever
4. Sudden escape of clear fluid from the vagina
5. Abdominal or chest pain
6. Increase or decrease in fetal movement
*Sandovsky method= Normal: 10-12x/hr.
 Complications of Pregnancy
(danger signs)

7. PIH
 Rapid weight gain
 Over 2 lbs/week in 2nd tri, 1 lb/week 3rd tri
 Swelling of the face or fingers
 Flashes of light or dots before the eyes
 Dimness or blurring of vision
 Severe, continuous headache
 Decreased urine output
 Health Promotion

1. Self-care needs
1) Bathing
2) Breast care
3) Dental care
4) Perineal hygiene
5) Clothing
2. Sexual activity
 Health Promotion

3. Exercise
 220 – 20 (age of woman) = 200 x 70% = 140 bpm
4. Sleep
5. Employment
6. Travel
 Discomforts of early pregnancy
(1st Trimester)

1. Breast tenderness - wide strap bra

2. Palmar erythema – calamine lotion
3. Constipation
4. Nausea, vomiting and pyrosis (heartburn)
5. Fatigue - increase amount of rest & sleep
 Discomforts of early pregnancy
(1st Trimester)

6. Muscle cramps
 dorsiflex foot; elevate LE freq.,
 Due to decreased serum calcium levels,
increased serum phophorus levels, and
possibly, interference with circulation.
7. hypotension
 Discomforts of early pregnancy
(1st Trimester)

8. Varicosities - elevate leg 15-20 min 2x/day

9. Hemorrhoids
10. Heart palpitations - due to increased blood volume
11. Frequent urination
12. Abdominal discomfort
13. leukorrhea
 Discomforts of Middle to
Late Pregnancy

1. Backache – pelvic rock/tilt; squat instead of

bend
2. Headache – due to expanding blood volume
3. Dyspnea
4. Ankle edema – due to general fluid retention
5. Braxton Hicks contractions