Antepartum Flashcards
Barriers to Prenatal Care
Attitudinal
Women rely on advice from family and friends
Hurried exams perceived as unimportant
Depression from or denial of unintended pregnancy
Systemic Conflicts with working women’s schedules Loss of wages or jeopardized job Unavailability of child care Lack of transportation – especially in rural communities
Financial
Medicaid process - burdensome and lengthy
Ineligible for Medicaid and insufficient insurance
Determining EDD
What if LMP isn’t known? (4)
Näegele’s rule – add one year, subtract 3 months, and adding 7 days to LMP
Wheel
Fundal height: Measurement of uterine size
Ultrasound: Method used to measure fetal parts
Crown-to-rump measurements
Biparietal diameter (BPD) measurements
Prenatal visits
Schedule
Every 4 weeks for the first 28 weeks’ gestation
Every 2 weeks from 28 weeks’ until 36 weeks’
After week 36, every week until childbirth
Presumptive Indications (10)
Amenorrhea (cessation of menstruation)
Nausea & vomiting
Fatigue
Urinary frequency
↑ during 1st trimester (hormonal changes)
↓ in the 2nd trimester (uterus more abdominal)
↑ with 3rd trimester (fetus larger, quickening)
Breast changes
Perceived Fetal movement (quickening)
Skin changes
Probable Indications (7)
Abdominal enlargement
Cervical softening (Goodell’s sign)
Flexion and softening of uterus against cervix (Hegar’s sign)
Fetus pushes away from examiner’s fingers (Ballotment)
apparent at the 16th week of pregnancy
Irregular painless contractions (Braxton Hicks)
Blood flow through the placenta (Uterine Souffle)
HCG in urine
Positive Indications
Auscultation of fetal heart sounds
Fetal movements by examiner
Visualization of fetus via ultrasound
HCP Assessment
HEGAR
GOODELL
Physical Assessment Head to Toe Clinical Breast Exam Pelvic examination Manual measurement of Pelvic Adequacy Pelvic Inlet and Pelvic Outlet Shape of pelvis – suitability/ease of vaginal delivery
Prenatal visit
Maternal well-bring
Fetal Well-bring
Maternal Well-being Weight Urine -> protein, glucose Blood pressure Education/Counseling
Fetal Well-being
Fundal Height
Fetal heart beat
Prenatal Labs
Leopold Maneuvers
First: determine fetal body part that occupies uterine fundus
Second: determine location of fetal spine
Third: compare fundus with lower uterine segment
Fourth: determine ballottement; engagement
Determine where the back is to get a good fetal HR
where baby is facing and position
FHR
120 to 160 beats per minute
Fetoscope
Doppler ultrasound stethoscope
Electronic fetal monitoring for high-risk pregnancies
Non-stress test (NST)
Biophysical profile (BPP)
Fundal Height
Centimeters correlates with weeks of gestation
12 week uterus just above pubic bone
16 weeks halfway between pelvic bone and umbilicus
20 weeks to umbilicus
24 weeks 1-2 fingers above umbilicus
36 xiphoid process
36-38 weeks = highest and then baby drops shifting the head closer to the inlet
Basic Screening Tests at initial visit
Pap smear, STI cultures
U/A, Urine C&S
Ultrasound – if warranted by history or physical
Maternal serum labs
Maternal Serum Labs at initial visit
Blood type and Rh typing, antibody screen (ABO sensitization) Complete blood count with diff Syphilis (RPR/VDRL) HIV screen Tuberculosis screen TORCH Toxoplasmosis, “Other”, Rubella, Cytomegalovirus, Hepatitis surface antigen/DNA Rubella titer Lead level Drug screen Genetic screen for chromosome traits Sickle cell Cystic fibrosis Tay-Sachs
Conflicts from Cultural Influences
Communication
Role of Partner, family
Time orientation
Health Beliefs
Multiple Marker Screening test
14 to 22 weeks gestation (best at 16 -18 wks) Multiple Marker “Triple Marker” MSAFP, Quantitative Beta hCG, Estriol Elevated MSAFP -> Neural tube defect, anencephaly, omphalocele/gastroschesis, Low MSAFP -> Down Syndrome “Quadruple Marker” adds Inhibin-A
MSAFP = maternal serum alpha feto-protein
GTT
HIV
GBS
Timing
24-28 weeks
1-hr 50g glucose tolerance test (GTT) - only if indicated
35 to 37 weeks
HIV retest
Group Beta Strep (GBS) vaginal/rectal culture
Ultrasound
10
Detect pregnancy – can detect FHR @ 6 weeks
Gestational age
Most accurate in 1st trimester – 4 to 7 days
Routine: at 14 to 16 wks
Position of fetus
Position of placenta
Size & dates of fetus – SGA, IUGR, LGA
Any gross fetal anomalies – nuchal neck, extrophy
Evaluation of fetal status
Alloimmunization: ascites, edema, fetal heart size
First Trimester (9)
Respiratory Changes Cardiovascular Changes Gastrointestinal Changes Breast Changes Amenorrhea Vaginal Secretions
Uterine Changes:
Goodell’s sign – cervical softening
Chadwick’s sign (levels of estrogen that cause characteristic bluish purple color that extends to vagina and labia)
Hegar’s sign – flexion and softening of uterus against cervix
Maternal Psychological Responses: First Trimester
Uncertainty
Ambivalence
The self as primary focus
Role Transition throughout pregnancy
Progressively more aware of changes in her life
Mentors and support are critical
Factors Influencing
Psychosocial Adaptations
Age Multiparity Social support Absence of a partner Abnormal situation Socioeconomic status
Second Trimester
Enlarging abdomen
Ballottement: 4 – 5 months (sudden tap on cervix during vaginal exam may cause fetus to rise and rebound to original position)
Chloasma: 4 – 5 months (brownish patches on face)
Straie Gravidarum: 6 months (stretch marks)
Braxton Hicks contractions (irregular painless contractions)
Linea Nigra: 5 months
Vascular spiders (tiny red elevations branching in all directions)
Quickening: 20 wks primigravida, 16- 18 wks multigravida
Maternal Psychological Responses:
Second Trimester
Physical evidence of pregnancy Fetus as the primary focus Narcissism and introversion Body image Changes in sexuality Introverted 4 month increase in libido
Third Trimester
Waddling gait
Enlarging abdomen
Increased cardiac output
Placental senility – placenta starts to not be fully functional around 40 weeks and slows nutrients to infant
Lightening: primigravida/multigravida –> descent of fetal head, reduces pressure on diaphragm and makes breathing easier
Uterine souffle: soft blowing sound/maternal pulse
Maternal Psychological Responses:
Third Trimester
Vulnerability - lack of concentration, hard to get in and out of a chair
Increasing dependence
Preparation for birth
Nesting behavior, taking classes, appointments
Maternal Tasks of Pregnancy
RUBIN
Rubin Seeking safe passage Securing acceptance Binding in to unknown child Learning to give of self
Mimicry, role play, fantasy, search for role fit, grief work
Stages of Family Development
Duvall
Duvall
Prepare for role as childcare providers
Reorganize home, family member duties, patterns of money management
Reorient family relationships
Each pregnancy—adjust to transitions in relationships with each other, children
Paternal Adaptation
Involvement
Nurturer vs. Alienated
Minimal vs. Dominating
Couvade –> similar symptoms to mom
“Announcement” phase – father accepts pregnancy
“Moratorium” phase – adjusts to reality of pregnancy
“Focusing” phase – father becomes more involved and builds relationship
Adaptation of Siblings
Reactions influenced by age and level of involvement with pregnancy
Toddlers – Regression
Preschoolers – May not grasp reality of a baby in the family
School-age – Excited, happy
Adolescents
Prepared Childbirth, Prepared Parenting
Preconception Early pregnancy Exercise Childbirth preparation Refresher courses Cesarean birth preparation -- Planned Vaginal birth after cesarean birth (VBAC) Breastfeeding Parenting/infant care Postpartum Classes for other family members -- Fathers, Siblings, Grandparents
Cochrane Collaboration
What works
Epidural, spinal, inhalation (general anesthesia)
What may work
Not much evidence but good satisfaction:
Immersion, Relaxation, Acupuncture, Non-opioid, Massage,
Not much evidence, not much satisfaction:
Hypnosis, Biofeedback, Aromatherapy, TENS, IV opioids
Lamaze International
Desired Effect of Nursing Interventions:
(4)
[Alleviate] Pain intensity
Satisfaction with pain relief
Sense of control in labor
Satisfaction with childbirth experience
Lamaze International
Characteristics
Pyschoprophylactic – Stimulation/Response conditioning
Controlled breathing may reduce pain during labor
Labor “coach”
Focal point, memory prompts
Breathing patterns
Slow chest breathing, Accelerated/Decelerated, Pant - Blow (modified pace with emphasis blow), Pushing (blow repeatedly with short puffs when urge to push increases)
DON’T hold breath –> Valsalva maneuver can decrease maternal cardiac output and
compromise fetal circulation
“Natural Childbirth” – limited medication
Bradley Method of Natural Childbirth
Pregnancy and Childbirth are joyful, natural processes
12 week course
Natural childbirth -> no medications preferred
Exercises, relaxation, to prepare
Abdominal breathing, and massage to manage labor
Partner-coached -> an active role
During the pregnancy, labor, and early newborn period
Exercises
Pelvic rocking - influences baby’s position (rock back and forth through pregnancy)
Tailor sitting - strengthens lower back muscles
Other childbirth education instead of or in addition to
Dick-Read Method
Fear -> Tension -> Pain
Education reduces fear, which reduces pain
Leboyer
“Birth Without Violence”
Odent
Birthing pool of water to reduce low lumbar pain
HypnoBirthing
State of deep relaxation to block distractions, pain
Priority Nursing Diagnosis
ABCs Safety Maslow Hierarchy of Needs Physiological Comfort – warmth, pain management Fluids, Food, Elimination Safety - psychological Love and Belonging Self-Esteem Self-Actualization
Anticipatory Guidance
Appointment schedule Nutrition Calories/Weight gain Protein Vitamins Minerals/supplements Herbal supplements Exercise Breastfeeding Physiology of pregnancy Managing symptoms Warning signs Sleep patterns
Anticipatory Guidance x 2
Medication OTC medication Prescribed medication Sexuality Modifiable risks Work (physical & environmental stressors) Substance abuse Safety Seat belts Behavior/Lifestyle choices IPV
Pregnancy teens
Normal adolescent developmental tasks conflict with tasks of pregnancy May not seek prenatal care Non-compliant with care plan Not future oriented Acceptance of pregnancy hindered
Conflicting Developmental Tasks
Adolescence Personal value system Body image and sexuality Vocation or career Independence from parents Achievement of a stable identity
Pregnancy
Seeking safe passage
Acceptance of the pregnancy by self and others
Acceptance of the reality of the unborn child
Acceptance of the reality of parenthood
Giving of oneself to the child
Physiologic Anemia
dilution of hemoglobin concentration
Increase in plasma and the production of RBC does not speed up at the same pace as the increase in plasma
No symptoms of anemia
34 weeks gestation
Effleurage and sacral pressure
Slow massage of abdomen during contractions
Helps with back labor
