Prenatal Care of the Mother (Nursing) PDF

PRENATAL CARE OF THE MOTHER History Taking, Physical Examination and Preventive Health Care of the Pregnant Mother LESSON OBJECTIVES Assess mother & child’s health status Formulate nursing diagnoses Implement safe and quality nursing interventions Conduct ind...

PRENATAL CARE OF THE MOTHER History Taking, Physical Examination and Preventive Health Care of the Pregnant Mother LESSON OBJECTIVES Assess mother & child’s health status Formulate nursing diagnoses Implement safe and quality nursing interventions Conduct individual/ group health education activities Evaluate with the client the health outcomes  QUALITY ANTENATAL CARE Health systems should ensure that all Quality antenatal care should be providers are EMPOWERED AND available for all women to ensure a EQUIPPED with necessary skills and POSITIVE PREGNANCY experience. supplies.  PRENATAL CARE VISIT Initial Interview Chief complaints/ History of Past & Family Health History Demographic Data Social Profile concerns Illnesses Gynecologic History Obstetric History Systemic Assessment Laboratory Assessment Procedures at the First Visit INITIAL INTERVIEW: Antenatal Visit & Birth Plan Health History Demographic data Chief Complaints/Concerns History of Past & Family Illnesses Social Profile Antenatal Visits Regular antenatal visits are the pinnacle of a healthy pregnancy, and have important implications on both the mother and the fetus.  Q: Which of these is a benefit of antenatal visits? A. Ability to monitor pregnancy B. Establishing a good healthcare professional-patient relationship C. Ability to identify deviations in the pregnancy early D. Ability to administer interventions early E. All of the above Benefits of Antenatal Care Establish a Needed to Allow good track administration relationship progress of of between the the pregnancy interventions healthcare and detect and provide professional any support and mother deviations through early counselling  INITIAL INTERVIEW HEALTH HISTORY TAKING Detection of health risks Establishing a baseline Assess health data health history  INITIAL INTERVIEW DEMOGRAPHIC DATA Name of Marital Status Home/ Occupation Patient Residence Educational [ ] Single Address Age background [ ] Married Sex (Female) Contact Health [ ] Separated Numbers Insurance [ ] Widow  INITIAL INTERVIEW DEMOGRAPHIC DATA Name of Marital Status Home/ Occupation Patient Residence Educational [ ] Single Address Age background [ ] Married Sex (Female) Contact Health [ ] Separated Numbers Insurance [ ] Widow  INITIAL INTERVIEW CHIEF COMPLAINTS pregnancy test kit  INITIAL INTERVIEW HISTORY OF PAST ILLNESSES A. HISTORY OUTLINE ▪ Sexual Status ▪ History of Gynecologic ▪ Contraceptive Status problems ▪ Significant Health ▪ Menstrual History: LMP Problems ▪ Pregnancy History ▪ Systemic Illness ▪ Vaginal & Pelvic Infections ▪ Other hospitalizations ▪ Gynecologic Surgical ▪ Medications taken Procedures ▪ Habits & Allergies ▪ Urologic History ▪ Smoking history ▪ Pelvic Pain ▪ Alcohol usage ▪ Vaginal Bleeding ▪ Illicit drug usage  INITIAL INTERVIEW HISTORY OF FAMILY ILLNESSES ▪ Family History of Diseases (Diabetes, Hypertension) ▪ Illnesses and causes of death of fist-order relatives ▪ Congenital malformations, mental retardation and reproductive wastage ▪ Occupational and vocational history ▪ Social History ▪ Psychiatric ▪ Depression ▪ Physical abuse ▪ Sexual abuse (Incest/ Rape)  INITIAL INTERVIEW SOCIAL PROFILE Nutrition Profile Exercise & Patterns of Activities Medication Intake  Contains information on: Birth Plan Woman’s condition during  A written document pregnancy prepared during the first prenatal Preferences for her consultation. place of delivery and choice of birth attendant  Plans may change anytime during pregnancy if an Available resources abnormality develops.  Discussed by the patient with the skilled birth Preparations needed (in case of emergency) attendant. Sample Birth Plan Sample Birth Plan  GYNECOLOGIC HISTORY A. Menarche the first menstruation. Inquire about its duration (starts between 8 to 13 years of age) & characteristics (eg. Irregular, anovulatory, and infertile). B. Duration of menses usual length of menstrual flow (eg. 3 to 5 days). C. Intervals between menses average of 28 days mean interval between periods, although 21 to 35 days considered normal D. Characteristics of menstrual flow Amount may be described as scanty, normal or heavy.  GYNECOLOGIC HISTORY E. Presence of Mittelschmerz also called for mid-cycle pain. F. Date of Onset of Last Menstrual Period (LMP) Check if normal menstrual period and not implantation bleeding which coincides with expected menstrual flow G. Date of Past/Previous Menstrual period (PMP) menstrual period before the last with the same characteristics as the last menstrual period. H. Menstrual Abnormalities or Problems Amenorrhea, Dysmenorrhea, Metrorrhagia, Menometrorhagia/ Polyrrahagia, Premenstrual Syndrome (PMS) Pre-menstrual Syndrome (PMS) vs Pregnancy Symptoms  OBSTETRIC HISTORY ❖GRAVIDA: Number of pregnancies regardless or duration or outcomes; past and present pregnancies, irrespective of the outcome ▪ Nulligravida ▪ Primigravida ▪ Multigravida ▪ Grand Multigravida ❖PARITY or PARA: total number of pregnancies in which the fetus has reached the age of viability (after 20 weeks) and subsequently delivered whether dead or alive at birth  OBSTETRICAL SCORING: CODING RESULTS OF PREVIOUS PREGNANCIES  “T” –Term/Fullterm; total no. of infants born at more than 37 weeks AOG.  “P” –Preterm; refers to the no. of infants born between 20 to 37 weeks AOG. Note: Twins/Multiple infant is counted as one  “A” –Abortion; refers to no./ of pregnancies ending in abortion/terminated before age of viability or before 20 weeks)  “L” –Living; refers to the no. of children alive  “M” –Multiple Pregnancies G-T-P-A-L: Gravida-Term-Pretem-Abortion-Living PRACTICE OBSTETRICAL SCORING: 1. Rapunzel is 6 weeks pregnant and went to the clinic for a prenatal check up. Her previous two pregnancies ended in a live birth at 40 weeks. What is her G-P-T-P-A-L Score? G P (T P A L) PRACTICE OBSTETRICAL SCORING: 1. Rapunzel is 6 weeks pregnant and went to the clinic for a prenatal check up. Her previous two pregnancies ended in a live birth at 40 weeks. What is her G-T-P-A-L Score? G P (T P A L) 3 2 (2 0 0 2) G3 (2-0-0-2) or G3P2 (2-0-0-2) PRACTICE OBSTETRICAL SCORING: 2. Beauty, a 27 year old female is currently 16 weeks pregnant. She has 2 year-old twin girls that were born at 36 weeks gestation and a 5 year-old who was born at 40 weeks gestation. She had no history of miscarriage or abortion. What is her GTPAL Score? G P (T P A L) PRACTICE OBSTETRICAL SCORING: 2. Beauty, a 27 year old female is currently 16 weeks pregnant. She has 2 year-old twin girls that were born at 36 weeks gestation and a 5 year-old who was born at 40 weeks gestation. She had no history of miscarriage or abortion. What is her GTPAL Score? G P (T P A L) 3 3 (1 1 0 3) G3 (1-1-0-3) or G3P3 (1-1-0-3) PRACTICE OBSTETRICAL SCORING: 3. Anna visited the OB clinic because she was experiencing her fourth pregnancy. Her first pregnancy resulted in a spontaneous abortion at 8 weeks, the second led to the live birth of twin boys at both 38 weeks, and the third was another live birth of a daughter at 34 weeks. What is her GTPAL? G P (T P A L) PRACTICE OBSTETRICAL SCORING: 3. Anna visited the OB clinic because she was experiencing her fourth pregnancy. Her first pregnancy resulted in a spontaneous abortion at 8 weeks, the second led to the live birth of twin boys at both 38 weeks, and the third was another live birth of a daughter at 34 weeks. What is her GTPAL? G P (T P A L) 4 3 (1 1 1 3) G4 (1-1-1-3) or G4P3 (1-1-1-3) SAMPLE GPTPAL: ADx: G2P1 (1-0-0-1) FDx: G2P2 (2-0-0-2) ADx: G5 P3 (3-0-1-3) FDx: G5 P4 (3-1-1-4) G14P9 (7-2-5-9)  NAEGELE’S RULE: Estimating Estimated Date of Delivery(EDD) A. Determine the Last Menstrual Period (LMP) B. Consider the first day of the LMP C. Consider the month in numeric terms: Example: January = 1 February = 2 March = 3 April = 4 & so forth D. Use Naegele’s rule: Subtract three months and add 7 days to the first day of LMP, and/or add 1 year OR add 9 months and 7 days to the first LMP LMP from Jan. to LMP from April to Dec., March, use formula: use formula: +9 +7 -3 +7 +1 SAMPLE COMPUTATION: Given LMP is February 13, 2021 LMP from Jan. to Solution: 02/ 13/ 2021 March, use formula: (+) 9 + 7 +9 +7 11/ 20/ 2021 EDD= November 20, 2021 Given LMP is July 12, 2021. July = 7 Solution: 07/ 12/ 2021 LMP from April to (–) 03 + 07 +1 Dec., use formula: -3 +7 +1 04/ 19/ 2022 EDD of April 19, 2022 SAMPLE PROBLEM ANSWERS: EDD 1. Mrs. Jasmin has an LMP of April 3, 2021. Compute EDD. 2. Mrs. Belle has LMP of October 10, 2021. Compute EDD. 3. Mrs. Mulan has LMP of March 8, 2022. Compute EDD. 4. Mrs. Cinderella has LMP of January 19, 2022. Compute EDD. 5. Mrs. Snow White has LMP of August 21, 2022. Compute EDD. Note: Solve each and show your solution SAMPLE PROBLEM ANSWERS: EDD 1. Mrs. Jasmin has an LMP of April 3, 2021. Compute EDD. 01/10/2021 (EDD JAN. 10, 2022) 2. Mrs. Belle has LMP of October 10, 2021. Compute EDD. 07/17/2021 (EDD JULY 17, 2022) 3. Mrs. Mulan has LMP of March 8, 2022. Compute EDD. 12/15/2020 (EDD DEC. 15, 2022) 4. Mrs. Cinderella has LMP of January 19, 2022. Compute EDD. 10/26/2020 (EDD OCT. 26, 2022) 5. Mrs. Snow White has LMP of August 21, 2022. Compute EDD. 05/28/2021 (EDD MAY 28, 2023) Note: Solve each and show your solution ESTIMATING AGE OF GESTATION (AOG)  Gestational age/ Menstrual age: counting from the first day of the last menstrual period (LMP)  Average Gestational Age: 40 weeks or 280 days (10 lunar months); divided into three trimesters of three months each ESTIMATING AGE OF GESTATION (AOG) A. Determine the first day of the LMP. B. Subtract LMP from its month.  ex. LMP: Jan.8 (-) Jan. 31 = Jan. 23 C. Count from the remaining days and add the number of days in each month up to the Date of Visit (DOV). Ex. DOV: March 17, 2021  Solution: Jan.23 + Feb.28 + Mar.17 = 68 ESTIMATING AGE OF GESTATION (AOG) D. Divide the Total by 7 to get the result of the AOG in WEEKS. NOTE: Divide manually to obtain the remaining days. Do not use calculator. Solution: Jan.23 + Feb.28 + Mar.17 = 68 Total = 68 days ÷ 7 days AOG = 9 weeks & 5 days SAMPLE PROBLEM ACTIVITY: AOG 1. Mrs. Jasmin has an LMP of April 3, 2021. DOV: August 20, 2021. Compute AOG. LMP: April 3, 2021 Manual Solving: (-) April 30, 2021 19 weeks April 27 7 139 days + May 31 (-) 7 + June 30 69 + July 31 (-) 63 + Aug. 20 (D.O.V) 6 days Total= 139 days AOG=19 weeks & 6days SAMPLE PROBLEM ACTIVITY: AOG 1. Mrs. Jasmin has an LMP of April 3, 2021. DOV: August 20, 2021. Compute AOG. 2. Mrs. Belle has LMP of October 10, 2021. DOV: March 15, 2022. Compute AOG. 3. Mrs. Mulan has LMP of March 8, 2021. DOV: June 2, 2021. Compute AOG. 4. Mrs. Cinderella has LMP of January 19, 2022. DOV: June 2, 2022. Compute AOG. 5. Mrs. Snow White has LMP of August 21, 2021. DOV: March 15, 2022. Compute AOG. Note: Solve each number and show your solution SAMPLE PROBLEM ACTIVITY: AOG 1. Mrs. Jasmin has an LMP of April 3, 2021. AOG=19 AOG. DOV: August 20, 2021. Compute wks & 6days 2. Mrs. Belle has LMP of October 10, 2021. DOV: March 15, 2022. Compute AOG=22 wksAOG.& 2days 3. Mrs. Mulan has LMP of March 8, 2021. AOG=12wks DOV: June 2, 2021. Compute AOG. & 2days 4. Mrs. Cinderella has LMP of January 19, 2022. DOV: June 2, 2022. Compute AOG=19AOG. wks & 1day 5. Mrs. Snow White has LMP of August 21, 2021. DOV: March 15, 2022. Compute AOG. AOG= 29wks&3days Note: Solve each number and show your solution  SAMPLE PROBLEM: On June 16, 2022, Patient Aimee had her prenatal visit and OB check-up at SKPH. Her initial vital signs were taken and her last menstrual period was from October 13 to 17, 2021. Calculate the EDD: _________________ Calculate the AOG:___________________  SAMPLE PROBLEM: On June 16, 2022, Patient Aimee had her prenatal visit and OB check-up at SKPH. Her initial vital signs were taken and her last menstrual period was from October 13 to 17, 2021. Calculate the EDD: _________________ Calculate the AOG:___________________  ESTIMATING GESTATIONAL AGE  Established using certain clinical milestone which can be used to estimate date of pregnancy: ▪ Early Prenatal Care ▪ Quickening ▪ Ultrasound/ Ultrasonography ▪ Auscultation of Fetal Heart Tone (FHT) ▪ Fundic Height Quickening  is the first sensation/ perception of fetal movement by the mother and is felt as slight fluttering movement in the abdomen;  Fetal movements are described as jerky and convulsive at nine weeks (Van Dongen & Goudie,1980);  By 16 weeks, fetal muscle movement is strong enough to activate receptors on the maternal abdominal wall, which mother interprets as “the baby moving” (Jensen & Bobak, 1985) Quickening…  In general, Quickening occurs between 18 & 20 weeks, related to parity and placental location: a. Placenta on anterior uterine wall. Quickening occurs at mean gestational age at 19 weeks in primigravida & 17.5 weeks in multiparas. b. Placenta on posterior uterine wall. Quickening occurs at mean gestational age at 18 weeks in primigravida & 16.1 weeks in multiparas.  Guidelines for determining EDD based on quickening is to ADD 22 weeks for Primigravida and 24 weeks for Multiparas to the date of quickening  SYSTEMIC ASSESSMENT ❖General: Weight gain ❖Respiratory system ❖Cardiovascular system and any history of heart diseases ❖Gastrointestinal system ❖Genitourinary system (Renal) ❖Breast Assessment ❖Dental Assessment  SYSTEMIC ASSESSMENT  Pregnant woman’s Appearance and posture  Initial Height and Weight taking  Examine: Eyes, ears, nose & throat  Examine: Thyroid gland, chest, heart, breast & abdomen  Abdomen should be systematically examined in the following process: I-nspection P-alpation P-ercussion A-uscultation PHYSICAL EXAM PHYSICAL EXAM PHYSICAL EXAM Auscultation of Fetal Heart Tone (FHT)  Using an ordinary, unamplified stethoscope, occurs at 20 weeks (Knuppel & Brikker, 1986);  Detection of fetal heart sounds with a Delee fetoscope between 17 and 19 weeks’ gestation, may be used as a reliable landmark of gestational age when it coincides with menstrual history. B. Ultrasound stethoscope Fetoscope C. DeLee-Hillis A. Ultrasound fetoscope fetoscope or Doppler  Estimating Fundic Height FUNDIC HEIGHT is measured to estimate the Age of Gestation, Estimated Date of Conception & fetal growth rate 3 LANDMARKS for fundic height detection: ▪ Symphysis pubis: 12 weeks ▪ Umbilicus: 20 weeks ▪ Xiphoid process: 36 weeks BARTOLOMEW’S RULE Used to calculate AOG Height of fundus (determined by palpation & relating it to different landmarks in the abdomen: ▪ Umbilicus, ▪ Symphisis pubis, ▪ Xiphoid process  Estimating Fundic Height FUNDIC HEIGHT DOH prescribes in its Home-based Maternal Birth Record (HMBR) the following fundic height levels in the 2nd half of the pregnancy: ▪ Fifth month gestation: 20 cm ▪ Sixth month gestation: 21-24 cm ▪ Seventh month gestation: 25-28 cm ▪ Eight month gestation: 29-30 cm ▪ Ninth month gestation: 30-34 cm Equipment: Tape measure (cm) NOTE: Instruct the mother to void before taking fundic height for better results Steps in Fundic Height Taking MCDONALD’S METHOD  An indicator of uterine size in early pregnancy;  Fundic height in centimeters (cm) correlates well with weeks of gestation between 20 to 31 weeks (Olds, et.al. 1988) MCDONALD’S RULE Used to calculate AOG; helps in estimating fetal gestational age using the fundic height. Procedure: A. Explain the procedure to the client. B. Instruct the client to void/ empty the bladder. C. Measure the fundic height (FH) using McDonald’s rule (from symphysis pubis to top of the fundus  MCDONALD’S RULE… FORMULA: A. Computing in lunar months, multiply the fundic height by two (2), then divide by seven (7) 𝐹𝐻 𝑖𝑛 𝑐𝑚 x 2 Gestational Age in lunar months = 7 Problem 1: What is the estimated gestational age in months if the fundic height is 31.5 cm? 31.5 𝑐𝑚 x 2 64 SOLUTION: + = 9 months 7 7 MCDONALD’S RULE… Problem 2: What is the estimated gestational age in months if the fundic height is 21 cm? 21 𝑐𝑚 x 2 42 SOLUTION: + = 6 months 7 7 B. Computing in weeks, multiply the fundic height by eight (8) then divide by seven (7) 𝐹𝐻 𝑖𝑛 𝑐𝑚 x 8 Gestational Age in weeks = 7 MCDONALD’S RULE… Problem 3: What is the estimated gestational age in weeks if the fundic height is 36 cm? 36 𝑐𝑚 x 8 288 SOLUTION: + = 41-42 weeks 7 7 Problem 4: What is the estimated gestational age in weeks if the fundic height is 21 cm? 21 𝑐𝑚 x 8 168 SOLUTION: + = 24 weeks 7 7 REASONS for GREATER than or LESSER than Fundal Height indicates: GREATER than LESSER than Expected FH Expected FH 1. Multiple pregnancy 1) Fetal growth rate 2. Miscalculated LMP retardation 3. Polyhydramnios 2) Fetal death 4. Hydatidiform mole 3) Error in estimating 5. Fetal Macrosomia AOG 4) Oligohydramnios  Estimating Fetal Length HAASE’S RULE Used to determine length of fetus a. During 1st half of pregnancy, square the number of months b. During the 2nd half of pregnancy, multiply the number of months  Estimating Fetal Weight JOHNSON’S RULE Used to calculate Fetal weight in grams Determine fundic height (in cm) using tape measure and then identify the station: *Minus (-) station = above ischial spines (IS) *Plus (+) station = below ischial spines (IS) JOHNSON’S FORMULA A. For vertex at or above the IS: Subtract 12 (constant) from the fundic height, then multiply by 155 (constant) Formula: FH – 12 x 155 = FW in grams Problem 1: What is the estimated weight in grams of the fetus of Mrs. Y, given the following data: FH = 32 cm, cephalic-vertex presentation; station -2? Solution: 32cm – 12 x 155 = 3,100 grams JOHNSON’S FORMULA B. For vertex below IS: Subtract 11 (constant) from the fundic height, then multiply by 155 (constant). Formula: FH – 11 x 155 = FW in grams Problem 2: What is the estimated weight in grams of the fetus of Mrs. Z, given the following data: FH = 34 cm, cephalic-vertex presentation; station +3? Solution: 34cm – 11 x 155 = 3,565 grams LABORATORY ASSESSMENT ▪Pregnancy test (7-10 days after a missed period). ▪Blood test (8 weeks). ▪Urine test (8 weeks and every visit). ▪Dating ultrasound (8 weeks). ▪Non-invasive prenatal testing (NIPT; 10 weeks). ▪Chorionic villus sampling (CVS; 10-13 weeks) ▪ Urine test (every visit). ▪ Fetal heart rate monitoring (every visit). ▪ Glucose challenge screening (at 24-28 weeks). ▪ Maternal serum screen (at 15-20 weeks). ▪ Anomaly ultrasound (18-20 weeks). ❖Amniocentesis (15-20 weeks). ❖Glucose tolerance test (24-28 weeks)  NOTE: It is worth mentioning that women in the third trimester are encouraged to do a baby kick count, a simple at-home test that helps monitor baby's well-being by keeping track of his or her movement ▪Urine test (every visit). throughout the day. ▪FHR monitoring: Baby’s heartbeat ▪Group B streptococcus test (35-37 weeks). ▪Baby kick count ❖ Ultrasound (UTZ): 32-36 wks ❖ Non-stress test (NST): after 28 wks ❖ Biophysical profile (BPP): after 32 wks ❖ Contraction Stress test (CST): 34 weeks or later  Ultrasonography Biparietal diameter (BPD) –measurement between the 2 parietal eminences of the fetal skull, is useful in determining gestational age during 2nd trimester and considered by some as the most accurate method to use; BPD of mature fetus = 9.5 cm @ 36 weeks