Nursing Management During Pregnancy

Nursing Management During Pregnancy

• Prenatal care aims to optimize outcomes for both the mother and fetus, traditionally beginning in the first trimester.
• The goal of preconception care is to promote the health and well-being of the woman and her partner before pregnancy.
• Key components include identifying genetic risks, ensuring a healthy weight, and eliminating harmful substance use.
• Pregnancy/gestation typically lasts about 40 weeks, calculated from the last menstrual period (LMP).
• Pregnancy is divided into three trimesters: first (weeks 1-12); second (weeks 13-27); and third (weeks 28-40+).
• Prenatal care involves monitoring physical and psychological changes, providing anticipatory guidance, and preparing for labor and postpartum events (e.g., feeding choices, length of time off work).

Learning Objectives

• Summarize goals of prenatal care and scheduling of prenatal visits.
• Analyze key components of health history, including obstetric history (GTPAL).
• Calculate the estimated date of birth (EDB) using common methods (e.g., Naegele's rule).
• Characterize results of screening tests, assessments, and lab findings of prenatal patients at initial and subsequent visits.
• Describe and analyze tests used to monitor fetal well-being.
• Outline appropriate nursing management to promote maternal self-care and minimize discomforts.
• Identify danger signals in pregnancy and their possible causes.

Initial Prenatal Visit

• A thorough health history is crucial, including medical, family, nutritional, current medications, reproductive, and obstetric details.
• Psychosocial history, including mental health screening and risk assessment for intimate partner violence, is vital.
• Teaching regarding pregnancy, risk factors, and expected changes is essential.
• Labs, including blood tests and screenings (e.g., blood type, Rh factor, antibody screen, CBC, BMP/CMP, Rubella titers, HIV, Hep B, Syphilis, Toxoplasmosis) and determining the due date, are part of the initial visit.
• A baseline physical exam, including weight, vital signs, and pelvic exam, is conducted.

Periodic Prenatal Visits

• Frequency varies depending on gestational age. Visits are typically every 4 weeks (monthly) until 28 weeks, then every 2 weeks until 36 weeks, and every week until delivery.
• Essential maternal health assessments (e.g., blood pressure, weight, urine analysis) and fetal well-being assessments are completed during these visits.
• Interventions and anticipatory guidance are provided based on the individual needs and progress of the pregnancy.

Determination of Due Date

• Naegele's rule is a typical method: subtract three months from the first day of the LMP and add seven days.
• A more accurate method is fetal ultrasound for gestational age.

Risk Assessment

• Key factors in risk assessment include age (<16 or >35), weight (underweight or obese), history of pregnancy complications (abortions, miscarriages, stillbirths), substance use/abuse, physical abuse, history of preterm birth or anomalies, and socioeconomic status.

Initial Prenatal Visit Physical Assessment

• Vital signs (heart rate, blood pressure, temperature, respiratory rate), baseline weight, and pelvic exam.
• Fetal heart rate (FHT) is checked using Doppler ultrasound. First detection is typically around 8 weeks.

Physical Examination (Pelvic Exam)

• Examination of external and internal structures.
• Evaluation of the pelvis for suitability for vaginal birth (considering pelvic shape: gynecoid, android, anthropoid, platypelloid).

Initial Lab Work

• Blood type and Rh factor determination
• Antibody screen.
• Comprehensive Blood Count (CBC)
• Basic Metabolic Panel (BMP)/Comprehensive Metabolic Panel (CMP)
• Rubella titers
• HIV screening
• Hepatitis B surface antigen
• Rheumatic factor (RPR) or Venereal Disease Research Laboratory (VDRL) for syphilis screening
• Toxoplasmosis screening
• Pap smear and cultures (chlamydia, gonorrhea)
• Urinalysis
• Non-invasive prenatal testing using maternal blood to check fetal DNA

Initial Lab Work (continued)

• Noninvasive prenatal testing (NIPT): checks fetal DNA circulating in maternal blood, can determine gender.

Rh Incompatibility

• Rh-negative women need an antibody screen.
• Rh immune globulin (RhoGAM) is administered to prevent Rh sensitization during pregnancy and after childbirth.

Periodic Prenatal Visits (continued)

• Maternal health (e.g., blood pressure, weight, urine analysis) and fetal well-being are assessed.
• Fetal movement monitoring, fundal height (measurement of the size of the uterus).

Second Trimester

• Screenings such as ultrasound (anatomical survey), and quadruple screening (AFP, HCG, Estriol, Inhibin A) may be performed.
• Amniocentesis may be considered if indicated; this technique is used for genetic diagnostics and to evaluate fetal lung maturity.

Second/Third Trimester Screenings

• One-hour glucose tolerance test (GTT), to identify gestational diabetes; prefer NPO mother for this test.
• Repeat H/H and potentially antibody screen for Rh- mothers.
• RhoGAM is a protocol for Rh- mothers to prevent maternal-fetal complications.

Third Trimester (Final Month)

• Group B Streptococcus (GBS) cultures (vaginal/rectal) are obtained to assess the possibility of infection in the mother.
• Repeat labs (CBC for blood count, H/H for hematocrit, and platelet counts) are considered for high-risk patients.
• Ultrasound (for growth, placenta location)
• Non-stress test (NST) and biophysical profile (BPP) are often conducted.

Teaching Danger Signals

• Vaginal bleeding
• Fluid leakage (PPROM)
• Fetal movement absence
• Fever
• Abdominal pain
• Persistent vomiting
• Burning or painful urination
• Signs of preterm labor
• Symptoms of preeclampsia (e.g., severe headaches, epigastric pain, edema, visual changes)

Common Discomforts in Pregnancy (1st Trimester)

• Nausea/vomiting
• Urinary frequency
• Fatigue
• Breast tenderness
• Leukorrhea (increased vaginal discharge)
• Oral problems (salivation, gingivitis)
• Nasal stuffiness

Common Discomforts in Pregnancy (2nd & 3rd Trimesters)

• Heartburn
• Constipation
• Hemorrhoids
• Backaches
• Dizziness/lightheadedness
• Leg cramps
• Varicose veins

Routine Self-Care

• Take prenatal vitamins.
• Attend prenatal visits as scheduled.
• Routine dental care every 6 months.
• Avoid X-rays and exposure to radiation.
• Discuss medications and herbal remedies with healthcare providers.
• Avoid tobacco, alcohol, and illicit drugs.
• Monitor caffeine intake (limit to 200 mg/day).

Health Promotion Education During Pregnancy

• Fetal activity monitoring.
• Hygiene practices (baths, hot tubs).
• Travel/activity limitations.
• Work/employment discussions.
• Exercise/pelvic tilt, Kegel exercises.

Vaccines

• Tdap during the third trimester (every 10 years) for tetanus, diphtheria, and pertussis prevention.
• Annual influenza vaccination.
• COVID-19 vaccination.
• Avoid live attenuated vaccines (MMR, Varicella, nasal influenza).

Tobacco Use in Pregnancy

• Assess tobacco use and willingness to quit.
• Educate on smoking cessation.
• Any decrease in tobacco use is beneficial.
• Risks of smoking include miscarriage, intrauterine growth restriction (IUGR), placental abruption, preterm delivery, and increased risk of Sudden Infant Death Syndrome (SIDS).

Alcohol Use in Pregnancy

• Fetal Alcohol Syndrome (FAS) is associated with several health consequences for affected children.
• No safe level of alcohol consumption during pregnancy has been established.

Preventing Infections (TORCH)

• Toxoplasmosis: avoid undercooked meat and handling cat litter.
• Other infections (syphilis, varicella, mumps, herpes, hepatitis, HIV).
• Rubella screening
• Cytomegalovirus (CMV)
• Herpes simplex virus (HSV): Cesarean delivery may be required if active lesions

Sexual Activity

• No contraindication for intercourse in a healthy pregnancy (unless other health concerns are involved, e.g. PTL, placenta previa, or risk of miscarriage).
• Health conditions (e.g., PTL, placenta previa, threatened miscarriage) may require restrictions on sexual activity.

Monitoring Fetal Well-Being

• Fetal movement counts (kick counts), performed at home, are crucial.
• Fetal movement counts, <10 movements in 2 hours, require further evaluations.
• Non-invasive monitoring methods are used to assess the well-being of the developing fetus.

Ultrasounds

• Ultrasound is used for various purposes during pregnancy, including confirming pregnancy, ensuring fetal viability, determining fetal heart rate (FHR), gestational age, assessing fetal growth, monitoring fetal anatomy, evaluating fetal movement/position, assessing fetal genetic anomalies, and evaluating placenta function.

Methods of Ultrasound Scanning

• Transabdominal ultrasound, often using a full bladder to provide clarity, is commonly used.
• Transvaginal ultrasound is usually preferable during the early stages. Other considerations include assessing cervical length and internal anatomy.

Biophysical Profile (BPP)

• BPP is a reliable predictor of fetal well-being, combining ultrasound (Fetal breathing movements, Fetal movements, Fetal tone, Amniotic fluid volume) and non-stress test (NST).
• Scores range from 0 to 10. A score of 8-10 is generally considered normal, while a score below 6 might indicate fetal distress.

Nonstress Test (NST)

• NST measures fetal heart rate (FHR) accelerations in response to fetal movement.
• Reactive NST indicates appropriate fetal oxygenation.
• Nonreactive testing may require further investigations.

Nonstress Test (NST) Interpretation

• Reactive: ≥ 2 or more accelerations of 15 beats/min lasting 15 seconds or more in a 20-minute period.
• Nonreactive: does not meet reactive criteria.

Contraction Stress Test (CST)

• CST used to evaluate the response of the fetus to uterine contractions.
• Negative CST (no late decelerations): normal.
• Positive CST (late decelerations): abnormal; indicates potential for uteroplacental insufficiency.
• Equivocal: unclear or indeterminate results.

Amniocentesis

• Amniocentesis involves obtaining amniotic fluid samples.
• The sample can be used to evaluate fetal lung maturity.
• It's also used for genetic testing and locating the placenta.
• Rh-negative mothers require RhoGAM administration after this procedure.

Preparing for Labor & Delivery

• Choices include physicians, certified nurse midwives, doulas, and various birth options (hospital, birthing center, home).
• A birth plan should be in place.
• Childbirth classes and feeding choices.

Premonitory Signs of Labor

• Backache, energy burst (nesting), lightening (dropping), Braxton Hicks contractions, vaginal discharge.