CARE OF THE MOTHER/ FETUS during the PERINATAL period

Prenatal care
• A. ASSESSMENT
• HISTORY
• P.E.
• S/S of pregnancy
• Diagnostic procedures and lab exams
• Vital signs
• Common discomforts
• Danger signs
• Local and systemic changes of pregnancy

• B. Nursing diagnosis
• C. Planning/ intervention
• Health promotion./management Nutrition metabolic
• Elimination Activity/exercise
• Sleep/rest Cognitive/perceptual
• Self-perception/self concept Role-relationship
• Sexuality Coping-stress tolerance
• Value/ belief
• D. Evaluation
• E. Documentation

§ IMPORTANT FACTS A. 9 calendar months/ 10 lunar months/ 3 trimesters ( 1 lunar month is = 28

days
• 1st tri- the period of organogenesis,the most critical stage because this is the time when the fetus is most
susceptible to teratogens ( non genetic FXS/ conditions that can cause malformations to the fetus in
utero.
• 2nd tri- stage when rapid increase in length occurs
• 3rd tri- stage of most rapid growth & development due to fat deposition
• B. 38-42 weeks
• C. 280 days from LMP using menstrual age/gestational age
• 267 days from conception using ovulation age
• PRENATAL VISITS-1st tri-every 4 wks (monthly)
2nd tri-every 2 wks (2x/mo)
3rd tri-every week (4x/ mo)
PHIL DOH guidelines- 80% of pregnant woman should have at least 5 prenatal visits

Definitions of terms:
• Prenatal care/antenatal-refers to health care given to a woman & her family during pregnancy
• Antenatal nursing- starts from conception and fetal development to the beginning of labor
• It encompasses all aspects of health care delivery of a childbearing individual
 • GOAL: to provide maximum health to expectant mothers and their babies
• GRAVIDA-a pregnant woman. This refers to any pregnancy regardless of duration
• NULLIGRAVIDA - A woman who has never been pregnant.
• PRIMIGRAVIDA - A woman pregnant for the first time
• MULTIGRAVIDA-a woman who has had 2 or more pregnancies/ fetuses past age of viability. It
does not matter whether they were born dead or alive.
• Grandmultipara - A woman who has had six or more births past the age of viability.
• PARA- the no. of pregnancies that reached the age of viability
• a woman who has delivered a viable young (not necessarily living at birth).
• is used with numerals to designate the number of pregnancies that have resulted in the birth of a viable
offspring.
• PRIMIPARA - A woman who has delivered one child after the age of viability.
• NULLIPARA- a woman who has NEVER delivered a viable infant. This woman may have been
pregnant for several times before But her pregnancies terminated in abortion or before 20 weeks
• MULTIPARA- a woman who has completed 2 0r more pregnancies that reached the age of viability
• Preterm infant- an infant born before 37-38 weeks gestation
• Term infant- an infant born full term, reached 37-38 weeks till 40 wks
• Post term- born after 42 weeks gestation
• Parturient- a woman in labor
• Puerpara- a woman who has just delivered.

Maternal assessment

• GATHER- (greet, ask, tell, help, explain, refer)

• 1. ASK ( interview about PX data, menstrual HX, breast health, contraceptive use, medical & OB
history).
• A. personal data-
 Age- below 17 & above 35 y/o ( anemia, preeclampsia, prematurity/ HPN
 WEIGHT- low prepregnancy weight= prematurity, LBW, stillbirth, congenital defect, OBESE=DM,
hypertensive disorders, thrombophlebitis
 Height- less than 5ft=CPD
 OCCUPATION- handling of toxic substances & strenous labor places the woman at risk
 Civil status- unwed & unwanted are high risks
 B. OB HISTORY-past and present
 Comprehensive system of classifying pregnancy status (GTPAL or GTPALM
 T-the number of full term infants born at 37 weeks or after.
 P - the number of preterm infants born before 37 weeks.
 A - the number of spontaneous or induced abortion.
 L - the number of living children.
 M - Multiple pregnancies.
• EXAMPLE: a woman’s OB HX of 3 previous pregnancies w/ 1 full term, 1 born at 35 wks, an abortion
of 8 weeks
• G3P2 (1-1-1-2)
HX OF PRESENT PREGNANCIES (LMP/EDC/S & S/ discomforts)
• I. ESTIMATION OF EDD/EDC (expected date of delivery/ confinement)
  A. Nagele’s Rule- to calculate the EDD ,count backward 3 calendar months in which the last
menstrual period occurred. Using the date of the first day of this menses, add 7 days. Change the year if
necessary.
EX; month day year
LMP- April 3 2009
-3 +7 +1
EDC- Jan 10 2010

 II. AOG- to obtain AOG, count the weeks from LMP up to the date of clinic visit
1.LMP= APRIL 3 (SUBTRACT 30 -3 = 27) APRIL 27

MAY 31
JUNE 30
JULY 18
2. DIVIDE 106 with 7 DAYS = 106
AOG= 15 weeks & 1/7

• If the woman cannot remember her LMP, ask when she 1st felt the fetus move (18th week)
• To get EDC for primigravida, add 22 weeks to the date of quickening
• To get EDC for multigravida, add 24 weeks to the date of quickening
• EX: 18TH week
+ 22
AOG = 40 weeks

III. ASSESSMENT OF FUNDIC HEIGHT

Approximate fundic height at every lunar month
• Purpose: used to measure to estimate AOG, EDC & fetal growth rate
• Fundic height drops after 36 wks because of lightening.
` FUNDIC HT LUNAR MO.
7 cm 8 weeks
10.5cm 12 weeks
14.0cm 16 weeks
17.5cm 20 weeks
21.0cm 26 weeks
35.0cm 36 weeks
24.5cm 40 weeks

Other estimates to calculate AOG

 IV. MC DONALD’S RULE
 fundic height in CM X 2/7 = AOG in lunar months
 fundic height in CM X 8/7 = AOG in weeks
 Ex: 16 cm X 2 32/7 = 4mos, 4days
7 =

 16 cm X 8
7 = 128/7 =18 WEEKS,2 DAYS
• GREATER FUNDIC HEIGHT INDICATES:
 1. Multiple pregnancy
2. Miscalculated due date
3. Polyhydramnios
4. Hydatidiform mole
• LESSER FUNDAL HEIGHT indicates:
1. Fetal growth rate retardation
2. Fetal death
3. Error in estimating AOG
4. oligohydramnios

V. BARTOLOMEW’S RULE
• -USED TO CALCULATE AOG THROUGH HEIGH OF FUNDUS
• IT IS DETERMINED BY PALPATION AND BY RELATING IT TO THE DIFFERENT
LANDMARKS IN THE ABDOMEN: (umbilicus, symphysis pubis, xiphoid process)

HEIGHT OF FUNDUS TO DET. AOG

• 12 weeks= level of symphysis pubis

• 16 weeks=halfway bet. umb and S.P.
• 20 weeks=level of umbilicus
• 24= 2FB above umbilicus
• 30= MIDWAY BET UMB AND X.P.
• 34=just below the X.P.
• 40= lightening
• 36=level of xiphoid process

F. JOHNSON’S RULE
• USED TO CALCULATE FETAL WEIGHT OF IN GRAMS
• FUNDIC HEIGHT IN CM
MINUS N X K
= WT OF FETUS

K= 155 (constant)
N=12 (engaged)
N=11 (not engaged)

G. HAASE’S RULE
• IS USED TO DETERMINE LENGTH OF FETUS
• A. during the first half of pregnancy, square the number of months
• B. during the second half of pregnancy, multiply the no. of months by 5.
• Ex. 1: 5 months2 = 25 cm (length of fetus)
• Ex. 2: 7 mos X 5 = 35 CM.

PHYSICAL ASSESSMENT/ EXAMINATION

• CEPALO-CAUDAL
 • HEAD/ SCALP- HAIR GROWS FASTER, EXCESSIVE DRYNESS OF HAIR=POOR UTRITION
• EYES- PALE CONJUNCTIVA= ANEMIA/ PEIORBITAL EDEMA & VISUAL DISTURBANCES=
HPN
• EARS- BLOCKAGE OF EUSTACHAN TUBE DUE TO ELEVATED ESTROGEN LEVEL=NASAL
STUFFINESS
• NOSE-NASAL CONGESTION=ESTROGEN STIMULATION
• MOUTH & TEETH- SWOLLEN GUMS (ESTROGEN)
CRACKED CORNERS OF MOUTH=VIT DEF.
DENTAL CARRIES
• NECK- SLIGHT ENLARGEMENT DUE TO INCREASED BASAL METABOLIC RATE/ DEMAND
OF PREGNANCY
• BREAST-ENLARGED, DARK AREOLA, PROMINENT MONTGOMERY TUBERCLES,
COLUSTRUM
• RECTUM-HEMORRHOIDS
• EXTREMETIES-NO EDEMA (PIH), WADDLING GAIT (due to relaxation of pelvic joints )
• BACK-exaggerated lumbar curve (results from shifting of center of gravity)
• SKIN- linea negra, chloasma, striae, sspider nevi, palmar erythema

ABDOMINAL EXAMINATION
• Also called LEOPOLD’S MANEUVER
• DONE AFTER 24 weeks AOG when fetal outline can be palpated
• PREPARATION:
1. Cardinal rule: empty bladder
2. Dorsal recumbent
3. Properly drape/ explain procedure
4. Warm hands first/ cold stimulates uterine contractions
5. Use palm of hands, not fingers
ABDOMINAL EXAMINATION/ LEOPOLD’S MANEUVER
First maneuver
• PURPOSE: TO DETERMINE FETAL PART OCCUPYING THE FUNDUS
• PROCEDURE: USE BOTH HANDS, FEEL FOR THE FETAL PART,
EXAMINER STANDS ON ONE SIDE OF THE BED FACING THE
HEADPART
• FINDINGS:1. BREECH-round, smooth, w/ transverse groove of the neck
2. vertex- buttocks is soft, angular.
Second maneuver

• PURPOSE: to identify the location of the fetal back

• PROCEDURE: use gentle but deep pressure
• One hand steadies the uterus on one side, the other moves slightly on circular
motion from top to lower segment of uterus
• Feel for fetal back and small fetal parts
• FINDINGS: 1.small fetal parts feel nodula w/ numerous angular nodulations
2. fetal back feels smooth, hard, continuous plane- like structure

Third maneuver
• PURPOSE: to determine engagement of presenting part
• PROCEDURE: use thumb & finger, grasp the lower portion of the abdomen above
symphysis pubis, press-in slightly and make gentle movements from side to side
• FINDINGS: 1. presenting part is engaged if it is not movable
2. it is not engaged if it is movable

Fourth maneuver
• PURPOSE: to determine the degree of flexion of the FETAL HEAD
• PROCEDURE: face the foot part of the woman, palpate the fetal head pressing
downward about 2 inches above the inguinal ligament, use both hands
• FINDINGS:1. if descended deeply, only small portion of fetal head will be
palpated
2. if cephalic prominence or brow of the baby is on the same side of the small parts, the
head is flexed
3. if cephalic prominence is on the same side of the fetal back, the head is extended

INTERNAL EXAM/ VAGINAL EXAM

• PURPOSE: during the 1st clinic visit (private), physician performs IE to confirm pregnancy and length
of gestation (today, U/S))
• After 34 weeks, IE is done for plvic measurements (today, X-RAY PELVIMETRY)
• The MW/Nurse perform IE during labor only
• NURSING RESPONSIBILITY
E-EB-L-L-D-I (EXPLAIN, EMPTY BLADDER, LIGHTING, LITHOTOMY, DRAPE, INSTRUCT)
DONTS: HOLD breath, hold/squeeze nurse’s hand, close eyes tightly, clench fist, contract perineal muscles
AFTER CARE/ WASH/ OFFER TISSUE PAPER

LABORATORY/ DX TESTS (DOH standards)

1) Urine/urinalysis-
• performed accurately 42 days after the last menstrual period or 2 weeks after the first missed period.
The first urine specimen of the morning is the best one to use.
• Benedict’s T-to determine glycosuria
• Acetic acid test-proteinuria
• Bacteuria-(early abortion OR premature labor)
2) Blood TESTS
• 2,1, CBC- Hct / hgb ct, RBC -to detect anemia, WBC (INFECTION), PLATELET (BLOOT
CLOTTING ability)
• 2.2. Radio Immuno-Assays (RIA) can detect HCG in the blood 2 days after implantation or 5 days
before the first menstrual period is missed.
• 2.3.BLOOD TYPing/ Rh factor/ incompatibility-
mother= Rh (-)
fetus = Rh (+)
• 2.4. VDRL/WASSERMAN TEST- TO DETECT SYPHILIS
• 2.5. GONORRHEA CULTURE
• 2.6. RUBELLA ANTIBODY TITER- TO DETECT DEGREE OF PROTECTION AGAINST
GERMAN MEASLES
• RESULT: A TITER OF 1:8= INDICATES MOTHER IS AT RISK OF INFECTION
A TITER OF MORE THAN 1:8 TITER MEANS THAT MOTHER HAS IMMUNITY
AGAINST G.M.
2.7. hepa b- presence of HBsAg
2.8. HIV TEST- to detect HIV antibodies
2.9. cervical smears- CXcal CA or infections

SIGNS AND SYMPTOMS OF PREGNANCY

• PRESUMPTIVE (S) SIGNS /CHANGES
 Amenorrhea
 N&V
 Urinary frequency
 Breast tenderness and breast changes
 Excessive fatigue
.
PROBABLE (O) changes
 Goodell’s sign (cx)
 Hegar’s sign (lower uterine segment, (isthmus)
 Ladin’s sign- softening of the uterus
 Chadwick’s sign
 Piskacek’s or Braun von Fernwald’s sign-a palpable lateral bulge or soft prominence in one of the
locations where the uterine tube meets the uterus and is noted in the 7th-8th week of gestation.

Probable signs/ changes

 Abdominal enlargement
 Uterine souffle
 Ballottement- if the lower uterine segment is tapped sharply the examining hand, fetus can be felt to
bounce or rise up against the top of the examining hand
 Braxton Hick’s contractions- starts as early as 12th week that becomes stronger and harder as pregnancy
advances,
 Skin pigmentation- linea nigra, alba, chloasma/melasma/mask of pregnancy due to MSH (melanocyte
stimulating hormone secreted by pituitary during pregnancy

• POSITIVE (DX) SIGNS/ CHANGES

 FETAL HEART BEAT
 FETAL MOVEMENT
 POSITIVE FETAL ULTRASOUND/ X-RAY OUTLINING FETAL SKELETON

PRESUMPTIVE PROBABLE POSITIVE

1ST TRI Amenorrhea Goodle’s sign Gestational sac seen on U/S
N&V Hegar’s FHT by doppler
Breast changes Chadwick’s
Urinary frequency
Leukorhea
Chadwick
2ND TRI Quickening Ballottement Fetal skeleton by x-ray
Skin changes Uterine growth Funic souffle
Uterine souffle
BHC
Fetal outline
3RD TRI Urinary frequency FHT by stet

REPRODUCTIVE SYSTEM CHANGES

 CAL GLANDS SECRETE THICK MUCUS THAT FORMS MUCUS PLUG OR OPERCULUM
 Increased vaginal vascularization, discharge is thick, white,acidic (chadwick’s
 Breast size increases, nipple & areola become darker in color (montgomery T.)

• RESPIRATORY CHANGES
• DISPLACEMENT OF DIAPHRAGM CAUSES SHORTNESS OF BREATH
• NASAL STUFFINESS AND EPISTAXIS DUE TO EDMA AND VASCULAR CONGESTION BECAUSE OF
INCREASE ESTROGEN CONTENT

• CARDIOVASCULAR CHANGES
• HEART IS DISPLACED UPWARD, TO THE LEFT AND FORWARD
• BLOOD VOLUME INCREASES BY 30-50 %/ RBC VOL. INCREASES 20%-30%
• HEMATOCRIT DECREASES BY 7% CAUSING PHYSIOLOGIC ANEMIA
• PULSE RATE INCREASES 10-15 beats/ minute
• SUPINE HYPOTENSIVE SYNDROME OCCURS AT 2ND SEM

• GASTRO INTESTINAL CHANGES

• NAUSEA & VOMITING DURING 1ST TRI
 • PTYALISM , HEARBURN, FLATULENCE OCCUR DUE TO REDUCTION IN GASTRIC ACIDITY,
GROWING UTERUS AND SMOOTH MUSCLE RELAXATION

• URINARY SYSTEM CHANGES

• FREQUENCY OF URINATION DURING 1ST & 3RD TRI DUE TO ENLARGEMENT AND
COMPRESSION OF THE GRAVID UTERUS
• WOMANIS AT RISK FOR GLUCOSURIA

INTEGUMENTARY CHANGES
• LINEA, CHLOASMA, STRIAE

• SKELETAL SYSTEM CHANGES

• RELAXATION OF PELVIC JOINTS
• LUMBUDORSAL CURVE INCREASES

• ENDOCRINE SYSTEM CHANGES

• RISE IN THYROXIN (T4), 25 % INCREASE IN BASAL METABOLIC RATE
• APG releases PROLACTIN for LACTATION
• POSTERIOR PITUITARY releases OXYTOCIN (uterine contractions) AND VASOPRESSIN (vasoconstriction
and antidiuretic effect
• Increase INSULIN production
• HORMONES OF PREGNANCY
>HCG
>HUMAN PLACENTAL LACTOGEN
>ESTROGEN/ PROGESTERONE/ RELAXIN

PSYCHOLOGICAL ADAPTATION

PSYCHOLOGICAL TASK OF PREGNANCY

  BASED ON REVA RUBIN’S THEORY- ARE THE EMOTIONAL RESPONSES OF THE MOTHER
TO PREGNANCY

 1ST TRIMESTER- Ambivalence

 FOCUS: BODILY CHANGES
 DEVELOPMENTAL TASK: ACCEPTANCE of biological facts of pregnancy
“ I AM PREGNANT”-The unborn child is incorporated as part of the woman’s body image or part of herself.
 2nd TRI- where the mother feels well, happy and fantazises about
 Focus: self and growth & development of the baby
 DEVELOPMENTAL TASK- accepts the growing fetus as a separate individual to care for
“ I AM GOING TO HAVE A BABY”
3RD TRI- IS THE PERSONAL IDENTIFICATION OF THE APPEARANCE OF THE BABY
 FOCUS: BABY AND DELIVERY AND RESPONSIBLE PARENTHOOD
 DEVELOPMENTAL TASK: PREPARATION FOR CHILDBIRTH
“ I AM GOING TO BE A MOTHER”

• MINOR DISCOMFORTS OF PREGNANCY RELATED TO

− GIT
− MUSCULOSKELETAL
− CARDIOVASCULAR

MINOR DISCOMFORTS OF PREGNANCY

1. NAUSEA & VOMITING
− Possible cause:
− high levels of human chorionic gonadotropin (HCG) or progesterone,
− cultural expectations, emotional factors
− maternal body function, especially after a period of fasting (from night to
morning).

2. Heartburn/PYROSIS
• - is a burning sensation in the epigastric and sternal region. It results from relaxation of cardiac sphincter
and the decreased tone and mobility of smooth muscles which is due to increased progesterone thereby
allowing for esophageal regurgitation, decreased emptying time of the stomach, and reverse peristalsis.

NURSING INTERVENTIONS FOR HEARTBURN

• Eat frequent, small meals.
• Take sips of milk or hot tea.
• Eat slowly.
• Avoid overeating as well as spicy, fatty, and fried foods.

3. CONSTIPATION
• Predisposition to constipation due to oral iron supplement (side effect of iron therapy is constipation).
Some patients respond with diarrhea

NSG INTERVENTION FOR CONSTIPATION

• Drink at least six glasses of water per day.
 • Moderate exercise every day, especially walking.
• Maintain a regular schedule for bowel movements.
• Increase fiber in the diet.

4. HEMORRHOIDS
• Varicosities of the rectal veins occur commonly in pregnancy because of pressure on these veins from
the bulk of the growing uterus.

NURSING INTERVENTION
• Daily bowel evacuation to relieve constipation, Modified Sim’s position
• Instruct to assume a knee-chest position for 10 to 15 minutes at day’s end

DISCOMFORTS RELATED TO MUSCULOSKELETAL SYSTEM

5.BACKACHE
• is caused by relaxation of the sacroiliac joint which is due to increased hormones (steroid sex hormone
and relaxin) resulting in slight joint and muscle relaxation and increased mobility; and exaggerated
lumbar and cervico thoracic curves caused by changes in the center of gravity from the enlarging
abdomen and breast.
• Prevention of strain, which can cause backache, should begin early in pregnancy.

Nursing intervention for backache

• practice good posture and good body mechanics (use the pelvic tilt and bend at the knees).
• wear appropriate, well-fitting shoes.
• Apply local heat.
• Avoid long periods of standing.
• Stoop to pick up objects.
• Wear low-heeled shoes

6. Muscle Cramps – dorsiflexion

• Muscle cramps are caused by:
1. Compression of nerves supplying the lower extremities due to the enlarging uterus.
2. Reduced level of diffusible serum calcium or elevation of serum phosphorus in the bloodstream.

Nursing Interventions for Muscle Cramps

• Avoid fatigue and cold legs.
• Eat a diet the adequate calcium or prescribed calcium.
• Avoid pointing the toes. Straighten the leg and dorsiflex the ankle.

7. Supine hypotension (Vena Cava Syndrome

• CAUSED BY:
• pressure of the gravid uterus on the ascending vena cava when the woman is supine which decreases the
return of the blood.
• Symptoms include nausea, cold and clammy, feels faint, and hypotension
 Nursing interventions consist of advising the patient
• Get up slowly.
• Use the side-lying position, preferably on the left side.

Treatment once varicose veins have developed.

• Rest with legs and hips elevated.
• Wear support stockings before rising (getting up) if varicose veins are severe.
• Lie on the bed with legs extended at a right angle to the body.
• To relieve pain and swelling, take hot sitz baths or local application of stringent compresses (witch
hazel pads).

Nursing intervention consists of advising the patient to:

1. Avoid obesity.
2. Avoid lengthy standing or sitting
3. Avoid constrictive clothing
4. Avoid constipation bearing down
5. Elevate legs when sitting
6. Vitamin C may reduce the size of varicosities.

8. Varicose Veins
• Varicosity is an enlargement of lumen of a vein due to thinning and stretching of its walls.

Nursing Intervention consists of advising the patient to:

• Maintain good posture.
• Avoid prolonged standing or sitting
• Wear support stockings.
Treatment of ankle edema
• Elevate the feet as often as possible
• Apply support stockings before getting up.

Edema (Ankle Edema, Non-pitting to Lower Extremities)

• Edema is very common during pregnancy. Edema is caused by reduced blood circulation in the lower
extremities as the gravid uterus puts pressure on the large vessels. Edema is most noticeable at the end
of the day and it is normal in pregnancy as long as it is not accompanied by the following:
1. Proteinuria (the presence of an excess of serum proteins in the urine).
2. Edema of nondependent parts.
3. Sudden increase in weight.
4. Hypertension.

DANGER SIGNS OF PREGNANCY:

Sudden gush of fluid from vagina Persistent vomiting
Vaginal bleeding Dizziness, blurring of vision, double vision,
Temperature above 101ºF & chills spots before eyes
Swelling of hands, face, legs, or feet
Convulsions
Stomach pain
Decreased amount of urination
Painful urination
Absence of fetal movement
Premature rupture of the membranes

Abrutio placentae, Placenta previa

Lesions of the cervix or vagina, “Bloody show”
Infection
Hyperemesis gravidarum
High blood pressure
Preeclampsia/eclampsia
Preeclampsia/eclampsia
Preeclampsia/eclampsia
Preeclampsia/eclampsia
Kidney impairment or lack of fluid intake
UTI (Urinary Tract Infection)
Maternal medication, obesity, fetal death