Chapter 12 Nursing Management During Pregnancy Flashcards
Preconception Care
Promotion of the health & well-being of the woman and her partner before pregnancy
Goal of Preconception Care
Identify & modify biomedical, behavioral, & social risks to a woman’s health or pregnancy outcome via prevention & management interventions
Interconception Period
Time between pregnancies when a woman can improve her health status, especially if the prior pregnancy had a poor outcome or adverse events occurred
Focuses on risk-factors that can be modified and/or eliminated prior to conception to optimize birth outcomes
Preconception & Interconception Care
Both should occur any time a heath provider sees a a woman of reproductive age
Primary nursing care for women of child-bearing age should include a routine assessment of the woman’s reproductive goals & planning
Women who could potentially become pregnant should be assessed for preconception or interconception risks
- Women not intending for a pregnancy anytime soon: Preconception care should focus on contraception counseling & optimizing overall health that may be aggravated by pregnancy
Encourage 400-800 mcg of folic acid/day depending on risk profile w/ regular diet & exercise
Immunizations for Pregnant Women:
- Flu vaccine if planning pregnancy during flu season
- Rubella & varicella vaccines, if no evidence of immunity
- Tetanus/diphtheria/pertussis if lacking adult immunity
Guidelines for Preconception & Interconception Care
Individual responsibility across the lifespan: Each woman, man, and couple should be encouraged to have a reproductive life plan.
Consumer awareness: Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts.
Preventive visits: As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.
Interventions for identified risks: Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high-priority interventions (i.e., those with evidence of effectiveness and greatest potential impact).
Interconception care: Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birth weight, or preterm birth).
Prepregnancy check-up: Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy.
Health insurance coverage for women with low incomes: Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care.
Public health programs and strategies: Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.
Research: Increase the evidence base and promote the use of the evidence to improve preconception health.
Monitoring improvements: Maximize public health surveillance and related research mechanisms to monitor preconception health.
General Health History
Immunization status of the woman
Underlying medical conditions, such as cardiovascular, metabolic conditions, and respiratory problems or genetic disorders
Reproductive health data: Pelvic examinations, use of contraceptives, & STIs
Sexuality and sexual practices: Safer-sex practices and body image issues
Nutrition history and present status lifestyle practices including:
- Occupation and recreational activities
- Psychosocial issues: Levels of stress and exposure to abuse and violence
- Medication and drug use including: tobacco use, alcohol, OTC and prescription medications, and illicit drugs
- Support system, including family, friends, and community
Health History: Reason for Seeking Care
The woman commonly comes for prenatal care based on the suspicion that she is pregnant
She may report that she has missed her menstrual period or has had a positive result on a home pregnancy test
Ask the woman for the date of her last normal menstrual period (LMP)
Also ask about any presumptive or probable signs of pregnancy that she might be experiencing
Typically, a urine or blood test to check for evidence of human chorionic gonadotropin (hCG) is done to confirm the pregnancy
Health History: Past Medical History
Ask about the woman’s past medical and surgical history
- Conds that the woman has experienced in the past may be exacerbated or recur
Chronic illnesses, such as diabetes or heart disease, can increase the risk for complications during pregnancy for the woman and her fetus.
Ask about any history of allergies to meds, foods, or environmental substances
Ask about any mental health problems, such as depression or anxiety
- Gather similar information about the woman’s family and her partner.
Ask about her occupation, possible exposure to teratogens, exercise and activity level, recreational patterns (including the use of substances such as alcohol, tobacco, and drugs), use of alternative and complementary therapies, sleep patterns, nutritional habits, and general lifestyle
Ex) If the woman smokes during pregnancy, nicotine in the cigarettes causes vasoconstriction in the mother, leading to reduced placental perfusion.
Health History: Reproductive Health
Includes a menstrual, obstetric, and gynecologic history: Begins w/ a description of the woman’s menstrual cycle
- Including:
- Age at menarche
- # of days in her cycle
- Typical flow characteristics
- Any discomfort experienced
The use of contraception is also important, including when the woman last used it.
For women and their families, this estimated due date (EDD) represents the long-awaited birthday of their child and is a time frame around which many economic and social activities are planned.
- End point date provides:
- Guidance for the timing of specific maternal and fetal testing throughout pregnancy
- Gauges fetal growth parameters,
- Provides well-established timelines for specific interventions in the management of prenatal complication
In fact, critical decisions, such as preterm labor management, timing of postdate induction of labor, and identification of fetal growth restriction (FGR), are all based on the presumed gestational age of the fetus, which is calculated backward from the EDD
Ask the woman the date of her LMP to determine the estimated or EDD.
Nagele’s Rule for Calculating the Estimated Due Date (EDD)
1) Use the first day of the last normal menstrual period
Ex) 10/14/20
2) Subtract 3 from the number of months
Ex) 7/14/20
3) Add 7 to the number of days
Ex) 7/21/20
4) Adjust the year by adding 1 year
Ex) 7/21/21
5) Estimated due date (+ or - 2 weeks)
Ex Result: July 21, 2021
Health Promotion Activities: Preconception Screening
Ensure that the woman’s immunizations are up to date
Create a reproductive life plan to address and outline reproductive needs
Take a thorough history of both partners to identify any medical or genetic conditions that need treatment or a referral to specialists
Identify history of STIs & high-risk sexual practices so they can be modified
Complete a dietary history combined w/nutritional counseling
Gather info regarding exercise and lifestyle practices to encourage daily exercise for well-being & weight maintenance
Stress the importance of taking folic acid to prevent neural tube defects
Urge the woman to achieve optimal weight before a pregnancy
Identify work environment and any needed changes to promote health
What is the focus of prenatal care?
To reduce the risk of adverse health effects for the woman, fetus, & newborn by addressing modifiable risk factors and providing education about having a healthy pregnancy
What is the significance of the initial prenatal visit?
An ideal time to screen for factors that might place the woman and her fetus at risk for problems such as preterm delivery
- Also an optimal time to begin educating the client about changes that will affect her life
Recent research found that delayed initiation of prenatal care was associated with increased rates of NICU admissions
- The opportunity to improve maternal health and reduce adverse newborn outcomes was lost when prenatal care wasn’t sought
What are the 2 methods of prenatal care?
1) Individually
2) Centering
Individual Method of Prenatal Care
The traditional model where a pregnant woman sees her health care provider at specified interims throughout her pregnancy and all visits occur on a one-to-one basis
Centering Method of Prenatal Care
Involves groups of up to a dozen women in similar gestational ages meeting w/ their health care provider for 10 sessions of approximately 1.5 to 2 hours each
How long does the pre-embryonic stage last for?
1st 14 days
How long does the embryonic stage last for?
15 days to 8 weeks
How long does the fetal stage last for?
9 weeks to 40 weeks
What major fetal development milestone occurs at 4 weeks’ gestation?
Fetal heart begins to beat
What major fetal development milestone occurs at 8 weeks’ gestation?
All body organs are formed
8-12 weeks: Fetal heart tones heard by Doppler
What major fetal development milestone occurs at 16 weeks’ gestation?
Baby’s sex can be seen
What major fetal development milestone occurs at 20 weeks’ gestation?
Mother feels movement called quickening
Baby develops regular schedule of sleeping, sucking and kicking
Hands can grasp
Head hair, eyebrows, eyelashes prese
What major fetal development milestone occurs at 24 weeks’ gestation?
Activity increases, Fetal Resp. movements begin
What major fetal development milestone occurs at 28 weeks’ gestation?
Eyes begin to open and close, 2/3 its final size
What major fetal development milestone occurs at 38+ weeks’ gestation?
Baby gets antibodies from mother
What does uncontrolled diabetes put a pregnant woman at risk for?
Spontaneous abortion (Miscarriage)
Fetal anomalies
Preeclampsia
Fetal demise
Macrosomia
Neonatal hypoglycemia
Hyperbilirubinemia
Macrosomia
A newborn w/ excessive weight
Management of Pregnant Patients w/ Diabetes
Keep A1c level lower than 6.5% to reduce the risk of congenital anomalies, preeclampsia, macrosomia, and other complications
Fasting and postprandial self-monitoring of blood glucose are recommended to achieve glycemic control
- Due to increased red blood cell turnover, A1c is slightly lower during pregnancy
- The target A1: Lower than 6% to 7% to prevent hypoglycemia.
The ADA recommends targets for women with type 1 or type 2 diabetes as follows:
- Fasting: lower than 95 mg/dL
- 1-hour postprandial: lower than 140 mg/dL
- 2-hour postprandial: lower than 120 mg/dL
Insulin is the preferred medication for treating hyperglycemia in gestational diabetes as it doesn’t cross the placenta to a measurable extent
If oral hypoglycemic agents are used, they shouldn’t be the first-line therapy since there are no safety data from long-term studies yet
What is the most accurate method of dating a pregnancy?
Typically, a fetal ultrasound
Gravid (G)
State of being pregnant
Gravida/Gravidity
The total # of times a woman has been pregnant, regardless of whether the pregnancy resulted in a termination or if multiple infants were born from a pregnancy
Nulligravida
A woman who has never experienced pregnancy
Primigravida
A woman pregnant for the 1st time
Secundigravida
A woman pregnant for the second time
Multigravida
A woman pregnant for at least the third time
Para
The # of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not), counting multiple births as one birth event
Parity
Refers to the # of pregnancies NOT the # of fetuses, carried to the point of viability, regardless of the outcome
Nullipara (para 0)
A woman who has not produced a viable offspring
Primipara
A woman who has given birth once after a pregnancy of at least 20 weeks, commonly referred to as a “primip” in clinical practice
Multipara
A woman who has had two or more pregnancies of at least 20 weeks’ gestation resulting in viable offspring, commonly referred to as a “multip”
Prepping a Client for a Physical Exam
Instruct the client to undress and put on a gown.
Ask her to empty her bladder, and when doing so, to collect a urine specimen.
- Typically, this specimen is a clean-catch urine specimen that is sent to the laboratory for a urinalysis to detect possible UTIs
Begin the physical examination by obtaining vital signs, including blood pressure, respiratory rate, temperature, and pulse.
- Abnormalities such as an elevated BP may suggest pregestational hypertension, requiring further evaluation
- Abnormalities in pulse rate & respiration require further investigation for possible cardiac or respiratory disease
Measure the client’s ht and wht.
- If the woman weighs less than 100 lb or more than 200 lb or there has been a sudden weight gain, report these findings to the primary care provider; medical treatment or nutritional counseling may be necessary.
Head-to-Toe Exam: Head & Neck
Assess the head and neck area for any previous injuries and sequelae
Evaluate for any limitations in ROM
Palpate for any enlarged lymph nodes or swelling.
Note any edema of the nasal mucosa or hypertrophy of gingival tissue in the mouth; these are typical responses to increased estrogen levels in pregnancy.
Palpate the thyroid gland for enlargement
- Slight enlargement is normal, but marked enlargement may indicate hyperthyroidism, requiring further investigation
Head-to-Toe Exam: Chest
Auscultate heart sounds, noting any abnormalities
- A soft systolic murmur caused by the increase in blood volume may be noted
Anticipate an increase in heart rate by 10 to 15 beats per minute (bpm) (starting between 14 and 20 weeks of pregnancy) secondary to increases in cardiac output and blood volume
- The body adapts to the increase in blood volume with peripheral dilation to maintain BP
Auscultate the chest for breath sounds, which should be clear.
- Note symmetry of chest movement and thoracic breathing patterns.
-> Estrogen promotes relaxation of the ligaments and joints of the ribs with a resulting increase in the anteroposterior chest diameter
- Expect a slight increase in respiratory rate to accommodate the increase in tidal volume and oxygen consumption.
Inspect and palpate the breasts and nipples for symmetry and color
- Increases in estrogen & progesterone and blood supply make the breasts feel full and more nodular with increased sensitivity to touch.
- Blood vessels become more visible and there is an increase in breast size.
- Striae gravidarum may be visible in women with large breasts.
- Darker pigmentation of the nipple and areola is present, along with enlargement of Montgomery glands.
- Colostrum is excreted typically in the third trimester
Striae Garvidarum
Stretch marks
Colostrum
Yellowish secretion that precedes mature breast milk
Head-to-Toe Exam: Abdomen
The appearance of the abdomen depends on the number of weeks of gestation
Inspection: The abdomen enlarges progressively as the fetus grows
- Inspect the abdomen for striae, scars, shape, and size.
- May reveal striae gravidarum and the linea nigra depending on the duration of the pregnancy
Palpation: Abdomen should be round & non-tender
- Decrease in muscle tone due to influence of progesterone
Linea Nigra
A thin brownish-black pigmented line running from the umbilicus to the symphysis pubis
Where can the fundus be palpated at 12 weeks’ gestation?
Can be palpated over the symphysis pubis
Where can the fundus be palpated at 16 weeks’ gestation?
Can be palpated midway between the symphisis & umbilicus
Where can the fundus be palpated at 20 weeks’ gestation?
Can be palpated at the umbilicus
Measured ~20 cm from the symphysis pubis
Where can the fundus be palpated at 36 weeks’ gestation?
Can be palpated just below the xiphoid process
Measures ~ 36 cm
Head-to-Toe Exam: Extremities
Inspect and palpate both legs for dependent edema, pulses, and varicose veins
- If edema is present in early pregnancy, further evaluation may be needed to rule out gestational hypertension
During the third trimester, dependent edema is a normal finding
- Ask the woman if she has any pain in her calf that increases when she ambulates -> might indicate a DVT
High levels of estrogen during pregnancy place women at higher risk for DVT
In what position should a client lay in for a pelvic exam?
The lithotomy position & draped appropriately
Pelvic Exam: External Genitalia
Should be free from __ upon inspection:
- Lesions
- Discharge
- Hematomas
- Varicosities
- Inflammation
Culture for STIs may be collected at this time
What are internal genitalia examined with?
A speculum
Pelvic Exam: Internal Genitalia
Cervix: Long, thick, & closed
- Goodell, Chadwick, & Hegar’s Sign are due to increased pelvic congestion
-> Goodell: Cervix will be softened
-> Hegar: Uterine isthmus will be softened
-> Chadwick: Bluish-purple coloration of the cervix & vaginal mucosa
Uterus: Usually pear-shaped & movable
- Will enlarge and become ovoid shape throughout pregnancy
Pap Smear & additional cultures (Chlamydia & gonorrhea) obtained
Rectal Exam: Assess for lesions, masses, prolapse, & hemorrhoids
Bi-Manual Pelvic Exam
Performed to estimate the size of the uterus to confirm dates and to palpate the ovaries
- The ovaries should be small and nontender without masses.
At the conclusion of the bimanual examination, the health care provider reinserts the index finger into the vagina and the middle finger into the rectum to assess the strength and regularity of the posterior vaginal wall
Purpose of CBC Testing in Maternal Care
Evaluates hemoglobin (12–14 g) and hematocrit (42% ± 5%) levels and RBC count (4.2–5.4 million/mm3) to detect the presence of anemia
Identifies WBC level (5,000–10,000 mm−3), which if elevated, may indicate an infection
Determines platelet count (150,000–450,000 mL3) to assess clotting ability
Purpose of Blood Typing in Maternal Health
Determines woman’s blood type and Rh status to rule out any blood incompatibility issues early
Rh-negative mother would likely receive RhoGAM (at 28 weeks’ gestation) and again within 72 hours after childbirth if she is Rh-sensitive
Purpose of Rubella Titer Testing in Maternal Health
Detects antibodies for the virus that causes German measles
- If titer is 1:8 or less, the woman is not immune
Requires immunization after birth, & the woman is advised to avoid people with undiagnosed rashes
Purpose of Hep B Testing in Maternal Health
Determines if the mother has hepatitis B by detecting presence of hepatitis antibody surface antigen (HbsAg) in her blood
Purpose of HIV Testing in Maternal Health
Detects HIV antibodies and if positive, requires more specific testing, counseling, and treatment during pregnancy w/ antiretroviral meds to prevent transmission to fetus
Purpose of STI Screening in Maternal Health
Detects STIs (such as syphilis, herpes, HPV, gonorrhea) so that treatment can be initiated early to prevent transmission to fetus
Purpose of Cervical Smear Testing in Maternal Health
Detects abnormalities such as cervical cancer (Pap test) or infections such as gonorrhea, chlamydia, or group B streptococcus so that treatment can be initiated if positive
Recommended Follow-Up Visit Schedule for Healthy Pregnant Women
Every 4 weeks up to 28 weeks (7 months)
then
Every 2 weeks from 29 to 36 weeks
then
Every week from 37 weeks to birth
Assessments:
- Weight and BP: Compared w/ baseline values
- Urine testing for protein, glucose, ketones, & nitrites
- Fundal height measurement to assess fetal growth
- Assessment for quickening/fetal movement to determine fetal well-being
- Assessment of fetal heart rate (should be 110 to 160 bpm
When is screening for gestational diabetes best done?
Between 24–28 weeks
High-Risk Reasons for Diabetes Screening in the 1st Trimester
Obesity
Older age
Family hx of diabetes
Hx of gestational diabetes
Ethnicity
- Hispanic
- Native American
- Asian
- African American
What is the main focus of a 29–36 weeks gestation assessment?
All the assessments of previous visits are completed, along with assessment for edema.
- Special attention is focused on the presence and location of edema during the last trimester.
Pregnant women commonly experience dependent edema of the lower extremities from constriction of blood vessels secondary to the heavy gravid uterus.
What additional screening occurs between 37–40 weeks’ gestation?
Screening for group B streptococcus, gonorrhea, and chlamydia is done.
Fetal presentation and position (via Leopold maneuvers) are assessed.
Review the signs and symptoms of labor, and forward a copy of the prenatal record to the hospital labor department for future reference.
Review the client’s desire for family planning after birth as well as her decision to breastfeed or bottle-feed
Remind the client that an infant car seat is required by law and must be used to drive the newborn home from the hospital or birthing center.
Fundal Height
AKA “McDonald” Method
The distance measured with a tape measure from the top of the pubic bone to the fundus w/ the client lying on her back with her knees slightly flexed
Measured in cm
What is the significance of measuring a pregnant woman’s fundal height?
It reflects fetal growth & provides a gross estimate of the duration of the pregnancy
- Fundal height increases as pregnancy progresses
Pregnancy Progression & Fundal Height
12-14 weeks’ gestation fundal ht: Above the symphysis pubis
20 weeks’ gestation fundal ht: 20 cm (Reaches umbilicus level)
Fundal measurement will continue to be an approximate match to the number of weeks until 36-38 weeks gestation
- Ex) 24 weeks gestation fundal ht = 24 cm
36–38 weeks’ gestation: Fundus reaches the xiphoid process
40 weeks’ gestation: Fundus drops below 38 weeks’ gestation level as presenting part drops into the pelvis
Fetal Growth Restriction (FGR)
Rate of growth does not meet the expected growth pattern
Infants will be born smaller
When does the perception of fetal movement occur?
Typically in the 2nd trimester
Quickening
When a pregnant person starts to feel their baby’s movement in their uterus (womb)
Described as “fluttering”
Significance of Monitoring Fetal Movements
Decreased fetal movement is associated w/ a range of pregnancy pathologies and poor pregnancy outcomes
- May indicate asphyxia and FGR
If compromised, the fetus decreases its oxygen requirements by decreasing activity
- Reduced fetal movement is thought to represent fetal compensation in a chronic hypoxic environment due to inadequacies in the placental supply of oxygen and nutrient
What is a method to keep track of fetal movements?
Kick Counts
How to Accurately Measure Kick Counts
Urge the client to perform the counts in a relaxed environment and a comfortable position, such as semi-Fowler or side-lying.
Provide the client with detailed information concerning fetal movement counts, and stress the need for consistency in monitoring (at approximately the same time each day) and the importance of informing the health care provider promptly of any reduced movements.
Providing clients with “fetal kick count” charts to record movement helps promote adherence to instructions.
- No values for fetal movement have been established that indicate fetal well-being, so the woman needs to be aware of a decrease in the number of movements when last assessed.
The most common method used is “Count to 10,” with which a woman focuses her attention on her fetus’s movement and records how long it takes to document 10 movements.
- If it takes longer than 2 hours, the woman should contact her health care provider for further evaluation.
How is fetal HR auscultated?
Fetal heart rates are auscultated w/ a doppler
Normal Fetal Heart Rate Range
110–160 bpm
Nursing Procedure: Measuring Fetal Heart Rates
1) Assist the woman onto the examining table and have her lie down.
2) Cover her with a sheet to ensure privacy, and then expose her abdomen.
3) Palpate the abdomen to determine the fetal lie, position, and presentation.
4) Locate the back of the fetus (the ideal position to hear the heart rate).
5) Apply lubricant gel to abdomen in the area where the back has been located.
6) Turn on the handheld Doppler device, and place it on the spot over the fetal back.
7) Listen for the sound of the amplified heart rate, moving the device slightly from side to side as necessary to obtain the loudest sound
- Assess the woman’s pulse rate and compare it to the amplified sound.
- If the rates appear the same, reposition the Doppler device.
8) Once the fetal heart rate has been identified, count the number of beats in 1 minute and record the results.
9) Remove the Doppler device and wipe off any remaining gel from the woman’s abdomen and the device.
10) Record the heart rate on the woman’s medical record; normal range is 110 to 160 bpm.
11) Provide information to the woman regarding fetal well-being based on findings
Danger Signs During the 1st Trimester
Miscarriage: Spotting or Bleeding
Infection: Painful urination, fever higher than 100 F (37.7 C)
Hyperemesis gravidarum: Severe persistent vomiting
Ruptured ectopic pregnancy: Lower abdominal pain w/ dizziness, accompanied by shoulder pain
Danger Signs During the 2nd Trimester
Preterm Labor: Regular uterine contractions
DVT: Pain in calf (increased w/ foot flexion)
Prelabor Rupture of Membranes: Sudden gush or leakage of fluid from vagina
Possible fetal demise/distress: Absence of fetal movement for more than 12 hrs
Danger Signs During the 3rd Trimester
Any of the 1st & 2nd Trimester Danger Signs can be present in the 3rd trimester
Gestational HTN & or Preeclampsia:
- Sudden weight gain
- Periorbital or facial edema
- Severe upper abdominal pain, or headache w/ visual changes
Possible Demise: Decrease in fetal daily movement for more than 24 hrs
Signs of Preterm Labor
Contractions every 10 mins or more frequently
Change in vaginal discharge
Pelvic pressure
Low, dull backache
Pelvic cramps
Diarrhea
High-Risk Pregnancies
Include those that are: Complicated by maternal or fetal conditions (coincidental with or unique to pregnancy) that jeopardize the health status of the mother and put the fetus at risk for uteroplacental insufficiency, hypoxia, and death
Ultrasonography
High-frequency sound waves that may be directed, through the use of a transducer, into the maternal abdomen.
The ultrasonic sound waves reflected by the underlying structures of varying densities allow identification of various maternal and fetal tissues, bones, and fluids
Ultrasound Uses
Location and presence of early pregnancy
Gestational Age and maturity
Fetal weight
IUGR
Polyhydraminos
Oligohydraminos
Fetal Death
Placenta location
Biophysical Profile
Fetal lie and presentation
Polyhydraminos
Abnormally high levels of amniotic fluid
Oligohydraminos
Abnormally low levels of amniotic fluid
Alfa-fetoprotein (AFP)
A glycoprotein produced initially by the yolk sac and fetal gut, and later predominantly by the fetal liver
What is the optimal time for AFP screening?
Between 16-18 weeks’ gestation
What correct info is vital for an accurate AFP screening?
Gestational dating
Maternal weight
Race
# of fetuses
Insulin dependency
Conditions that Increase Maternal Serum AFP Levels
- Serum AFP levels increase until ~14–15 weeks’ gestation, then fall progressively*
Open neural tube defects
Underestimation of gestational age
Presence of multiple fetuses
GI defects
Low birth weight
Oligohydramnios
Maternal age
Diabetes
Decreased maternal weight
Conditions that Decrease Maternal Serum AFP Levels
Fetal gestational age is overestimated or in cases of fetal death
Hydatidiform mole
Increased maternal weight
Maternal type 1 diabetes
Fetal trisomy 21 (Down syndrome) or trisomy 18 (Edward syndrome)
Nursing Management of AFP Testing
AFP Testing requires a venipuncture for blood sample
- Has now been combined w/ other biomarker screening tests (triple, quad, or penta screens) to determine the risk of neural tube defects and Down syndrome
Gathering accurate information about the date of her LMP, weight, race, and gestational dating
- Accurately determining the window of 16 to 18 weeks’ gestation will help ensure that the test results are correct
Also explain that the test involves obtaining a blood specimen
Amniotic Fluid
Protective fluid that surrounds the fetus in utero
Functions of Amniotic Fluid:
- Thermoregulation
- Protects the fetus & absorbs shock
- Aids in the growth & development of the lungs
- Prevention
Amniocentesis
Procedure that is done to obtain amniotic fluid for testing involving a transabdominal puncture of the amniotic sac
Indications for Amniocentesis
Diagnosis of genetic disorders or congenital anomalies
Assessment of pulmonary maturity
Diagnosis of hemolytic disease
Risk Factors of Amniocentesis
Maternal or Infant Infection
Fetal-Maternal Hemorrhage
Lower abdominal discomfort and cramping that may last up to 48 hours after the procedure
Spontaneous abortion (one in 300 to 500)
Postamniocentesis chorioamnionitis that has an insidious onset
Leakage of amniotic fluid in 2% to 3% of women after the procedure
Higher rates of fetal loss in earlier amniocentesis procedures (earlier than 15 weeks’ gestation) versus later ones
Normal Findings in Amniotic Fluid Analysis
Color: Clear with white flecks of vernix caseosa in a mature fetus
Bilirubin: Absent
Meconium: Absent (except in breech position)
Creatinine: >2 mg/dL in a mature fetus
Glucose: < 45 mg/dL
AFP: Variable, depending on gestation age and laboratory technique; highest concentration (about 18.5 ng/mL) occurs at 13–14 weeks
Bacteria: Absent
Abnormal Findings in Amniotic Fluid Analysis
Color: Blood of maternal origin is usually harmless. “Port wine” fluid may indicate abruptio placentae. Fetal blood may indicate damage to the fetal, placental, or umbilical cord vessels
Bilirubin: High levels indicate hemolytic disease of the neonate in isoimmunized pregnancy
Meconium: Presence indicates fetal hypotension or distress
Creatinine: Decrease may indicate immature fetus (<37 weeks)
Glucose: Excessive increases at term or near term indicate hypertrophied fetal pancreas and subsequent neonatal hypoglycemia
AFP: Inappropriate increases indicate neural tube defects such as spina bifida or anencephaly, impending fetal death, congenital nephrosis, or contamination of fetal blood
Bacteria: Presence indicates chorioamnionitis
Chorionic Villus Sampling
An invasive procedure involving an 18-G needlestick through the abdomen or passage of a suction catheter through the cervix under ultrasound guidance
Purpose: Used to obtain a sample of the chorionic villi from the placenta for prenatal evaluation of chromosomal disorders such as Down syndrome or cystic fibrosis, enzyme deficiencies, and fetal gender determination and to identify sex-linked disorders such as hemophilia, sickle cell anemia, and Tay–Sachs diseas
Nursing Management of Chorionic Villus Sampling
Explain to the woman that the procedure will last about 15 minutes
Ultrasound will be done 1st to locate the embryo, and a baseline set of vital signs will be taken before starting
Make sure she is informed of the risks related to the procedure, including their incidence.
If a transabdominal CVS procedure is planned, advise her to fill her bladder by drinking increased amounts of water
A needle will be inserted through her abdominal wall and samples will be collected
- Once the samples are collected, the needle will be withdrawn and the samples will be sent to the genetics laboratory for evaluation
Nonstress Test
Evaluation of fetal response (fetal heart rate) to natural contractile uterine activity or to an increase in fetal activity
Steps in Performing a Nonstress Test
Before the procedure, the client eats a meal to stimulate fetal activity.
Place client in the left lateral recumbent position to avoid supine hypotension syndrome
An external electronic fetal monitoring device is applied to her abdomen.
-The device consists of two belts, each with a sensor.
- One of the sensors records uterine activity, while the second sensor records fetal heart rate.
The client is handed an “event marker” w/ a button that she pushes every time she perceives fetal movement.
- When the button is pushed, the fetal monitor strip is marked to identify that fetal movement has occurred
The procedure usually lasts 20 to 30 mins
Reactive/ Reassuring Finding
At least 2 accelerations that occur with movement lasting 15 seconds with increase of 15 beats in 20 minutes
Non-Reactive/ Non-reassuring Finding
Characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame
A nonreactive test has been correlated with a higher incidence of fetal distress during labor, fetal mortality, and IUGR. Additional testing, such as a biophysical profile, should be considered
Nursing Management of NST (Nonstress Test)
Before NST:
- Explain the testing procedure and have the woman empty her bladder
- Position her in a semi-Fowler position and apply the two external monitor belts
- Document the date and time the test is started, client information, the reason for the test, and the maternal vital signs
- Obtain a baseline fetal monitor strip over 15 to 30 min
During the Test:
- Observe for signs of fetal activity with a concurrent acceleration of the fetal heart rate
- Interpret the NST as reactive or nonreactive
After the NST:
- Assist the woman off the table, provide her with fluids, and allow her to use the restroom
- The health care provider discusses the results w/ the woman at this time
- Provide teaching about signs and symptoms to report
- If serial NSTs are being done, schedule the next testing session
Biophysical Profile (BPP)
Uses a real-time ultrasound and NST to allow assessment of various parameters of fetal well-being that are sensitive to hypoxia
Each row is 2 pts (Max is 10 pts)
Components of a BPP
Fetal Movements: 3 body/limb movements
Fetal Tone: 1 episode of active flexion & extension of the limbs + opening & closing of the hands
Fetal Breathing Mvmnt: Episode that lasts more than or greater than 30 secs in 30 mins
Amniotic Fluid Volume: Single 2 cm X 2 cm is considered adequate
Non-stress Test: 2 accelerations > 15 bpm of at least 15 secs duration
1st Trimester of Pregnancy Discomforts
Nausea and Vomiting
Urinary Frequency/Urgency
Fatigue
Breast Tenderness
Nasal Stuffiness and Epistaxis
2nd & 3rd Trimester of Pregnancy Discomforts
Heartburn (Pyrosis)
Hemorrhoids
Ankle Edema: Pitting is NOT normal
Varicosities
Leg Cramps: Baby is sitting on sciatic nerve
Round Ligament Pain
Nursing Management of Urinary Frequency/Incontinence
- Try pelvic floor exercises to increase control over leakage.
- Empty your bladder when you first feel a full sensation.
- Avoid caffeinated drinks, which stimulate voiding.
- Reduce your fluid intake after dinner to reduce nighttime urination
Nursing Management of Fatigue
Attempt to get a full night’s sleep without interruptions.
- Eat a healthy balanced diet.
- Schedule a nap in the early afternoon daily.
- When feeling tired, pause and rest
Nursing Management of N/V
Avoid an empty stomach at all times.
- Eat dry crackers/toast in bed before arising.
- Eat several small meals throughout the day.
- Avoid brushing teeth immediately after eating to avoid gag reflex.
- Acupressure wristbands can be worn daily.
- Drink fluids between meals rather than with meals.
- Avoid greasy, fried foods or ones with a strong odor, such as cabbage or Brussels sprouts
Nursing Management of Backaches
Avoid standing or sitting in one position for long periods.
- Apply heating pad (low setting) to the small of your back.
- Support your lower back with pillows when sitting.
- Use proper body mechanics for lifting anything.
- Avoid excessive bending, lifting, or walking without rest periods.
- Wear supportive low-heeled shoes; avoid high heels.
- Stand with your shoulders back to maintain correct posture
Nursing Management of Leg Cramps
Elevate legs above heart level frequently throughout the day.
- If you get a cramp, straighten both legs and flex your feet toward your body.
- Ask your health care provider about taking additional calcium supplements, which may reduce leg spasms
Nursing Management of Varicosities
Walk daily to improve circulation to extremities.
Elevate both legs above heart level while resting.
Avoid standing in one position for long periods of time.
Don’t wear constrictive stockings and socks.
Don’t cross the legs when sitting for long periods.
Wear support stockings to promote better circulation
Nursing Management of Hemorrhoids
- Establish a regular time for daily bowel elimination.
- Avoid constipation and straining during defecation.
- Prevent straining by drinking plenty of fluids and eating fiber-rich foods and exercising daily.
- Use warm sitz baths and cool witch hazel compresses for comfort
Nursing Management of Constipation
Increase your intake of foods high in fiber and drink at least eight 8-oz glasses of fluid daily
When developing a plan of care, the nurse needs to make which assessments for a pregnant client with a BMI of 18.3? Select all that apply.
A) Assess for maternal fatigue
B) Assess for poor fetal growth
C) Assess for preterm labor
D) Assess for gestational diabetes
E) Assess for eclampsia
A, B, & C
Rationale: With a low prepregnancy BMI of 18.3, this client needs to be monitored for complications related to deficient nutrient stores such as fatigue, poor fetal growth, and preterm labor. A low BMI does not place this client at high risk for gestational diabetes or eclampsia
