Antepartum Care

Antepartum care refers to the medical and nursing care given to the pregnant woman between conception and the onset of labor. Goal of prenatal care is to have a healthy mother and a healthy baby, through identification of risk factors, assessment for complications, and education of the mother.

Pregnancy history - described in terms of gravida and para - GTPAL method

- Example: A woman who is 13 weeks pregnant and reports a history of 1 term delivery, 1 preterm delivery of an infant that did not survive, and no abortions or miscarriage.

Calculation of due date

1. Nageles Rule - determines expected date of delivery 2. Fetal measurements - determines gestation age and due date 3. Fundal height - estimates the number of weeks of gestation

Prenatal visits
1. Initial prenatal visit

- detailed history
- physical examination

- initial laboratory studies

2. Subsequent prenatal visits - monthly until 28 weeks of gestation biweekly until 36 weeks of gestation weekly until birth

Prenatal visits
2. Subsequent prenatal visits
- usual physical assessments - Leopolds maneuvers are performed after 32 weeks - Laboratory tests: a. MSAFP, estriol, and hCG is done between weeks 14 and 18 to detect some fetal abnormalities. b. Diabetes screening and a CBC are done between weeks 25 and 28. - At week 36, vaginal exam is performed

Prenatal Education
Topics include: - health promotion during pregnancy - discomforts of pregnancy - complications of pregnancy - preparation for labor and birth - postpartum concerns

Patient Teaching about Complications of Pregnancy Possible Complication Hyperemesis gravidarum Infection Spontaneous abortion or miscarriage Premature rupture of membranes Danger Signs to Report Persistent vomiting Fever and chills, burning on urination, diarrhea Abdominal cramps, vaginal bleeding Leakage of fluid from the vagina

Premature labor

Menstrual-like cramps, low backache, pelvic pressure, 4 or more contractions in an hour

Patient Teaching about Complications of Pregnancy Possible Complication Hypertensive conditions Danger Signs to Report Blurred or double vision, spots before the eyes, severe headache, swelling off ace or fingers, convulsions, upper abdominal pain, decrease in the amount of urine Vaginal bleeding, sudden or sharp severe abdominal pain, decrease in the amount of urine Diminished or absent fetal movement

Placental problems

Fetal problems

Evaluation of Fetal Well-being A. INDIRECT TECHNIQUES 1. Measurement of fundal height - gives information about the growth of the fetus

2. Maternal weight gain

Evaluation of Fetal Well-being A. INDIRECT TECHNIQUES

3. Maternal serum screening for alpha fetoprotein (AFP), estriol, and human chorionic gonadotropin (hCG) - detects fetal anomalies, fetal death
4. Fetal movement

Evaluation of Fetal Well-being B. DIRECT TECHNIQUES - Noninvasive 1. Auscultation - FHR is checked before, during and at least 30 seconds after a contraction 2. Ultrasound - visualize the fetus, placenta, umbilical cord, and amniotic fluid

Evaluation of Fetal Well-being B. DIRECT TECHNIQUES - Noninvasive 3. Nonstress test (NST) - uses an electronic fetal monitor - measures the response of the fetal heart rate to fetal movement - done if the pregnant woman has risk factors that may lead to diminished placental functioning

Evaluation of Fetal Well-being B. DIRECT TECHNIQUES - Noninvasive 4. Biophysical profile (BPP) - evaluates a fetus at risk for inadequate placental perfusion - assesses 5 variables: fetal heart rate during a NST body movement muscle tone breathing movements amniotic fluid volume during an ultrasound

Evaluation of Fetal Well-being B. DIRECT TECHNIQUES - Invasive 1. Chorionic villus sampling (CVS) - a needle is inserted through the vagina or abdominal wall - performed at weeks 10 to 12 of pregnancy - test for genetic abnormalities 2. Amniocentesis - insertion of an ultrasound-guided needle through the mothers abdomen into the uterine cavity - early pregnancy (weeks 15 and 18) to detect chromosomal abnormalities - late pregnancy (weeks 30 to 35) to determine fetal lung maturity - lecithin/ sphingomyelin (L/S) ratio --- 2:1 indicates fetal lung maturity

Evaluation of Fetal Well-being B. DIRECT TECHNIQUES - Invasive 3. Percutaneous umbilical blood sampling (PUBS) - collection of fetal blood after 18 weeks of gestation for testing of blood disorders, infection or genetic disorders - ultrasound-guided needle is inserted through the mothers abdomen into the fetal umbilical vein

Evaluation of Fetal Well-being B. DIRECT TECHNIQUES - Invasive 4. Contraction stress test (CST) - evaluates response of FHR to controlled uterine contractions with the use of fetal monitor - determines the ability of the fetus to tolerate the contractions of labor - contractions are stimulated by either nipple stimulation or the use of intravenous oxytocin

Nutritional Requirements
- Additional 300 calories per day - Protein increases by 10 g to 14 g to a total of 60 g

- Carbohydrate intake needs to be sufficient

- Calories from fat should not exceed 30% of the daily intake - Daily calcium needs remain at 1200 mg

- Iron intake increases from 15 mg to 30 mg

- All women of childbearing age should take 400 micrograms of folic acid daily to prevent neural tube defects in the first trimester

Foods to avoid
1. Alcohol - can result in fetal alcohol syndrome (FAS) - FAS causes prenatal and postnatal growth failure, microcephaly, facial and musculoskeletal abnormalities and mental retardation 2. Caffeine - increases heart rate, urine production, and secretion of acid in the stomach - causes low birth weight - Switch to decaffeinated beverages 3. Artificial sweeteners and additives

4. Cholesterol

Management of Discomforts during the first trimester 1. NAUSEA AND VOMITING - Avoid greasy, highly seasoned food - Eat small, frequent meals - Eat dry toast or crackers before getting out of bed in the morning 2. NASAL STUFFINESS, DISCHARGE, OR OBSTRUCTION - Use a cool-moist humidifier - Use of normal saline nose drops or nasal spray - Apply cool compresses to the nasal area 3. BREAST ENLARGEMENT AND TENDERNESS - Use a well-fitting bra with shoulder straps for support - Maintaining good posture - Wash breast and nipple area with water only

Management of Discomforts during the first trimester 4. URINARY FREQUENCY AND URGENCY - Decrease fluid intake in the evening to minimize nocturia - Limit intake of caffeinated beverages - Respond to the urge to void to prevent bladder distention and urine stasis - Report signs and symptoms of urinary tract infection 5. INCREASED LEUKORRHEA - Bathe daily and avoid using soap on the vulvar area - Wipe vulvar area from front to back - Wear loose, absorbent cotton underwear - Avoid tight pants and pantyhose - Use panty liners or perineal pads - Avoid douching - Notify health care provider if the discharge changes in color or odor

Management of Discomforts during the first trimester 6. INCREASED FATIGUE - Frequent rest periods - Balanced diet with iron supplementation - Warm milk or warm shower or bath before going to bed at night to aid in relaxation - Moderate regular exercise

Management of Discomforts during the second and third trimesters 1. HEARTBURN - Eat small, frequent meals - Avoid fatty and fried foods and caffeine products - Remain upright for at least 1 hour after eating - Refer to health care provider before using antacid 2. CONSTIPATION - Engage in moderate daily exercise - Increased intake of fluids and foods high in fiber - Maintain regular elimination patterns - Avoid ignoring the urge to defecate - Use stool softeners as needed

Management of Discomforts during the second and third trimesters 3. HEMORRHOIDS - Caution against prolonged standing and wearing constrictive clothing - Topical ointment or anesthetic if allowed - Sitz baths or apply warm soaks - Lie on left side with feet slightly elevated 4. BACKACHE - Proper body mechanics - Maintain good posture - Wear low-to-mid-heel shoes - Walk with pelvis tilted forward - Apply local heat to the back - Sleep on a firmer mattress - Pelvic rocking or tilting exercises

Management of Discomforts during the second and third trimesters 5. LEG CRAMPS - Evaluate calcium to phosphorus ratio in the diet - Frequent rest periods with legs slightly elevated - Wear warm clothing - During an attack, pull toes up toward the leg while pressing down on the knee

6. SHORTNESS OF BREATH - Maintain proper posture - Semi-fowlers position when sleeping - Use additional pillows for support - Balance of activity and rest

Management of Discomforts during the second and third trimesters 7. ANKLE EDEMA - Lie on left side in bed - Avoid wearing tight, constrictive clothing - Dorsiflex feet when standing or sitting for prolonged periods - Get up and move about every 1 to 2 hours when sitting for long periods

8. VARICOSE VEINS - Elevate legs - Wear support hose - Avoid crossing legs at the knee, restrictive clothing, and standing for long periods of time

Management of Discomforts during the second and third trimesters 9. FAINTNESS - Arise slowly - Avoid prolonged standing - Maintain hematocrit and hemoglobin 10. Flatulence - Avoid gas-forming foods - Chew food thoroughly - Establish regular bowel movements