Ante Partum

Health Promotion and Pregnancy: Antepartum

Christensen Foundations of Nursing Chapter 25

Fetal Development• Gestation – begins with conception (fertilization

with union of sperm and egg) and continues throughout birth and pregnancy– Lasts 40 weeks– 3 trimesters of 3 months each

• Fertilization – the union of the egg and the sperm to form a zygote– 2 weeks after the last normal menstrual period

(LMP or LMNP)– Sex is determined at fertilization– Occurs in outer 1/3 of fallopian tube

Fetal Development

• Implantation – occurs when the zygote (blastocyst) enters the endometrium of the uterine fundus between 6-10 days after conception– Decidua – endometrium after implantation

• Chorionic villi – fingerlike projections that develop out of the trophoblast (developing placenta) and extend into the maternal blood vessels of the decidua

Fetal Intrauterine Development• Ovum stage – conception to day 14

– Morula blastocyte germ layers• Embryo stage – day 15 to 8 weeks

– Greatest risk from teratogens– Most organ systems and external

structures develop• Fetal stage – 9 weeks until completion of

pregnancy– Recognizable as a human

Fetal Development• 4 weeks – fetal heart begins to beat, body

flexed, C-shaped with arms and leg buds present

• 8 weeks – all organs formed, first indication of musculoskeletal ossification (first 8 weeks are the most critical)

• 8-12 weeks – fetal heart rate can be heard using a doppler

• 12 weeks – sex can be determined, blood forming in marrow, kidneys secrete urine

Fetal Development

• 16 weeks – face looks human, meconium in bowel, heart muscle well developed, sensory organs differentiated

• 20 weeks – primitive respiratory movements, heartbeat heard with fetoscope, quickening (fetal movement), brain grossly formed, vernix caseosa (protective, cheese like coating) on the skin, and lanugo (fine, downy hair), viable outside of the uterus (has some chance of life outside of the uterus)

Vernix Caseosa and Lanugo

Fetal Development• 24 weeks – body lean, well proportioned,

lecithin (respiratory marker) begins to appear in amniotic fluids, able to hear

• 28 weeks – brown fat present, eyes open and close, weak suck reflex

• 32 weeks – subcutaneous fat collecting, has fingernails/toenails, sense of taste, aware of sounds outside mother’s body

• 34+ weeks – skin pink, body rounded, scant vernix caseosa, lanugo on shoulders and upper body only, fetus receives antibodies from mother

Fetal Development• Growth and development, before and after birth,

follows the cephalocaudal (head to toe) principle• Fetus has 4 specialized circulatory pathways:

– Ductus arteriosus – connects pulmonary artery to the aorta bypassing lungs

– Foramen ovale – opening between atria shunting blood from right to left atria

– Ductus venosus – shunts blood from umbilical vein to the IVC bypassing liver

– Placenta

Ductus Arteriosus and Foramen Ovale

The Placenta

• Produces hormones needed to maintain pregnancy

• Performs the metabolic functions of respiration, nutrition, excretion, and storage

• Maternal oxygen diffuses across the placenta into the fetal blood

• Carbon dioxide diffuses from the fetal blood across the placenta into the maternal blood

The Placenta

The Amniotic Fluid

• Suspends the embryo/fetus• Maintains constant fetal body temperature• Source of oral fluid and repository for fetal waste• Cushions fetus to prevent injury• Allows fetal movement for musculoskeletal

development• Prevents the amnion (inner placental

membrane) from fetal adherement• Prevents umbilical cord compression

The Umbilical Cord

• Connects fetal blood vessels contained in the placental villi with those within the fetal body

• Consists of 2 arteries that carry deoxygenated blood from the fetus to the placenta

• Consists of 1 vein that supplies the embryo with oxygen and nutrients from the placenta

• Wharton’s jelly – thick substance that surrounds the umbilical cord acting as a physical buffer to prevent pressure on the vessels

Presumptive Signs of Pregnancy

• Amenorrhea, nausea, vomiting, fatigue, urinary frequency, breast changes, uterine enlargement

• Quickening – fetal movement felt at 16-20 weeks gestation

• Linea nigra • Chloasma (melasma) – mask of pregnancy • Striae gravidarum – stretch marks• Darkened areola

Linea Nigra

Chloasma

Striae Gravidarum

Probable Signs of Pregnancy• Abdominal enlargement, cervical changes• Hegar’s sign – softening and compressibility of

lower uterus at 6-8 weeks pregnancy• Chadwick’s sign – violet-blue color of vaginal

mucosa• Goodell’s sign – cervical tip softening• Ballottement – rebound of unengaged fetus felt

in the 4th or 5th month of pregnancy• Braxton Hicks contractions• Positive pregnancy test, palpable fetal outline

Hegar’s Sign

Positive Signs of Pregnancy

• Fetal heart sounds– Fetoscope– Doppler

• Fetal movement palpated by an experienced examiner

• Visualization of fetus by ultrasound or through x-ray examination

Physiologic Changes in Pregnancy

• Reproductive – uterus increases in size and changes shape and position, ovulation and menses stop

• Cardiovascular – increase in cardiac output, blood volume, and heart rate

• Respiratory – maternal oxygen needs increase, size of chest may enlarge during last trimester (rib cage flaring)

• Musculoskeletal – weight increases, pelvic joints relax, lordosis of the lower back occurs

Physiologic Changes in Pregnancy

• Gastrointestinal – nausea and vomiting may occur, stomach and intestines are displaced

• Renal – increased GFR, urinary frequency• Endocrine – levels of estrogen and

progesterone rise till close of pregnancy, human chorionic gonadotropin (HCG) rises in early pregnancy then drops second trimester, and human placental lactogen (HPL) rises

Maternal Changes – 1st Trimester

• 1st month – implantation spotting, fatigue, headache, mood swings

• 2nd month – amenorrhea, positive pregnancy test, morning sickness, urinary frequency, tenderness or tingling of the breasts, fatigue, facial outbreaks, weight gain, may have heartburn

• 3rd month – fetal heartbeat by doppler above the symphisis pubis, fatigue, weight gain, less nausea, palpable uterus, linea nigra/chloasma

Maternal Changes – 2nd Trimester

• 4th month – less urination, increased energy, abdominal pulling, quickening (16-20 weeks)

• 5th month – uterus easily felt below umbilicus, quickening, increased , energy, constipation, darker areola, leukorrhea

• 6th month – back pain, leg and foot cramps, mild swelling in the ankles and feet, striae gravidarum, weight gain, fast growing hair and nails

Maternal Changes – 3rd Trimester

• 7th month – cramps in feet/legs, swelling in hands or feet, Braxton-Hicks contractions, stress incontinence

• 8th month – heartburn, indigestion, shortness of breath, varicose veins, hemorrhoids, Braxton-Hicks contractions, orthostatic hypotension

• 9th month – surge of energy, “lightening”, urinary frequency, improved breathing, loss of cervical mucus plug, rupture of membranes

Laboratory Tests • HCG (human chorionic gonadotropin) –

biochemical markers for pregnancy that can be detected in serum and urine

• Blood type, Rh factor, and presence of irregular antibodies – determines risk of maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia

• CBC with differential, Hgb, and Hct – detects anemia and infection

• Serum alpha-fetoprotein – detects neural tube defects such as spina bifida

Laboratory Tests• Hemoglobin electrophoresis – detects

hemoglobinopathies (sickle cell anemia and thalessemia)

• Urinalysis – identifies DM, gestational HTN, renal disease, infection, and hematuria

• One hour glucose tolerance – identifies gestational diabetes; done at initial visit for high risk clients, and at 24-28 weeks for all pregnant women (blood sugar > 135 mg/dL requires follow-up)

Laboratory Tests• Three hour glucose tolerance – screens for

diabetes in clients with elevated 1 hour glucose test, requires 2 elevated readings to confirm diagnosis

• Papanicolaou (PAP) test – screens for cervical cancer, herpes simplex type 2, and/or HPV

• Vaginal/cervical culture – detects group B streptococci (routinely obtained at 35-37 weeks), bacterial vaginosis, or STIs (gonorrhea and chlamydia)

Laboratory Tests

• Rubella titer – determines immunity to rubella (teratogen)

• PPD, chest screening after 20 week gestation with positive PPD – identifies exposure to tuberculosis

• Hepatitis B screen – identifies carriers• Venereal disease research laboratory (VDRL) –

syphyllis screening mandated by law• HIV – detects HIV infection (requires consent)

Laboratory Tests

• TORCH – acronym for a group of infections that can negatively affect a woman who is pregnant, and cross the placenta and have teratogenic affects on the fetus– Toxoplasmosis– Other infections– Rubella– Cytomegalovirus – Herpes virus

Toxoplasmosis• Caused by protozoan – Toxoplasma gondii• Domestic cats are the definative hosts with

infections via: ingestion of contaminated raw or undercooked meats and garden products and contact with cat feces

• Infection more prevalent in Europe• Maternal infection usually asymptomatic or has

influenza symptoms or lymphadenopathy• 33% risk of fetal infection if mother is infected

during pregnancy

Toxoplasmosis

• Most infants (70-90%) asymptomatic at birth but are high risk for developing abnormalities

• Classic fetal triad of symptoms: chorioretinitis, hydrocephalus, and intracranial calcifications

• Other symptoms include: fever, rash, microcephaly, seizures, jaundice, thrombocytopenia, lymphadenopathy

Rubella• Single stranded RNA viral disease that is

vaccine preventable and not endemic in the U.S.

• Mild, self limiting disease in adults with rash, muscle ache, joint pain, and lymphedema

• Infection early in pregnancy has a higher probability of affecting the fetus (teratogenic)

• In infants may cause sensorineural hearing loss, cataracts, glaucoma, cardiac malformations, neurologic problems, growth retardation, bone disease, thrombocytopenia, “blue berry muffin” lesions, and death

Blueberry muffin spots

Cytomegalovirus (CMV)• Most common congenital viral infection affecting

approximately 40,000 infants annually in the U.S.• Mild, self-limiting disease in adults that is usually

asymptomatic or has mononucleosis-like symptoms

• Transmission can occur with primary infection or reactivation of the virus with 40% risk of transmission to the infant in primary infection

• Studies suggest increased risk to the fetus if acquired late in the pregnancy

Herpes Simplex Virus • HSV 1 and HSV 2 that is primarily transmitted

through infected maternal genital tract lesions– Requires C-section prior to rupture of

membranes• Primary maternal infection has greater risk for

transmission than reactivation infection• Initial manifestations in infants very nonspecific• Infants may present with infection of the skin,

mouth, eyes, CNS disease, or disseminated disease

Diagnostic Tests• Ultrasound – (18-40 weeks) high frequency

sound waves are used to visualize internal organs and tissues by producing a 3 dimensional image of the fetus and maternal structure allowing for pregnancy confirmation, determining gestational age, identifying multi-fetal pregnancy, identifying site of implantation (uterine or ectopic), fetal viability, placental attachment site, and volume of amniotic fluid– External abdominal ultrasound– Internal transvaginal ultrasound

Transvaginal Ultrasound

Diagnostic Tests

• Doppler ultrasound blood flow analysis – external ultrasound method of studying the maternal-fetal blood flow by measuring the velocity at which the RBCs are traveling n the uterine and fetal vessels– Useful for identifying fetal intrauterine

growth problems, poor placental perfusion, and as an adjunct in high risk pregnancies

Diagnostic Tests• Nonstress test (NST) – doppler transducer and

tocotransducer are attached externally producing paper tracing strips during the third trimester to evaluate fetal heart rate (FHR), fetal movement, and the fetal nervous system during the third trimester– Reactive NST – FHR accelerates 15

beats/min for at least 15 seconds and occurs 2-3 times/20 minute period (normal)

– Nonreactive NST – FHR does not accelerate with fetal movement or no fetal movement occurs in 40 minutes (abnormal)

Nonstress Test (NST)

• The detection of fetal movement is important

• Instruct the mother to drink a fluid, have a snack, or to touch or rock the abdomen to move the fetus

Diagnostic Tests• Contraction stress test (CST) – an assessment

performed to stimulate contractions (which decrease placental blood flow) and analyze the FHR in conjunction with the contraction to determine how the fetus will tolerate labor– Negative CST (normal) - there are no late

decelerations of the FHR in a 10 minute period with 3 contractions

– Positive CST – (abnormal) persistent and consistent late decelerations on more than ½ of the contractions

Diagnostic Tests

• Biophysical profile (BPP) – uses a ultrasound to visualize physical and physiological characteristics of the fetus in response to stimuli

• 2 = normal, 0 = abnormal, total 8-10 = normal– Fetal heart rate (cardiotocogram)– Fetal breathing movements – Gross body movements (body or limb)– Fetal muscle tone and posture– Amniotic fluid volume and evaluation

Diagnostic Tests• Amniocentesis – (3rd trimester) aspiration of

amniotic fluid for analysis by insertion of a needle transabdominally into the uterus and amniotic sac when mother is > 35 years, has history of previous fetal or parental chromosomal anomaly, fetal hemolytic disease, and meconium in the fluid to test for:– Alpha-fetoprotein (AFP) – high levels

associated with neural tube defects– Fetal lung maturity – low levels associated

with Down’s syndrome and hydatidiform mole

Amniocentesis

Neural Tube Defect: Spina Bifida

Hydatidiform Mole• Benign abnormal uterine mass derived from

chorionic villi that appears as a “bunch of grapes”– Very large cystic vesicles

• U.S. incidence is 1 out of every 2000 pregnancies

• Early in the pregnancy maternal blood will present with high levels of hCG

• Associated with fertilization of the ovum by 2 or more sperm

Diagnostic Tests

• Chorionic villus sampling (CVS) – (8-12 weeks) assesses a portion of the developing placenta (chorionic villi) through aspiration using a thin sterile catheter or syringe passed through the abdomen or intravaginally to detect genetic chromosomal abnormality– First trimester alternative to amniocentesis– Does not detect spina bifida or anencephaly

Anencephaly

Danger Signs During Pregnancy

• First trimester – vaginal bleeding or spotting, pelvic/abdominal cramping, no longer feeling pregnant, excessive vomiting

• Second and third trimesters – vaginal bleeding with or without cramping, pressure, or pain, bleeding with severe abdominal pain, vaginal or lower abdominal pressure, preterm labor (PTL), premature rupture of membranes (PROM), decreased fetal movement, pregnancy induced hypertension (PIH)

Complications of Pregnancy

• Spontaneous abortion– When a pregnancy is terminated before 20

weeks gestation or a fetal weight of < 500 g

– S/S - vaginal bleeding, uterine cramping, backache, rupture of membranes, dilation of the cervix, partial or complete expulsion of products of conception, and signs and symptoms of hemorrhage

Spontaneous Abortion

Spontaneous Abortion• Threatened – may or may not have cramping,

spotting to moderate bleeding, cervix is closed• Inevitable – cramping, bleeding, dilated cervix• Incomplete – cramping, bleeding, partial fetal

tissue passed, dilated cervix• Complete – bleeding, complete expulsion of

uterine contents, closed cervix• Missed – brownish discharge, retained tissue,

closed cervix• Septic – malodorous discharge, dilated cervix• Recurrent – fetal tissue passed, dilated cervix

Spontaneous Abortion

• Perform pregnancy test

• Use term “miscarriage”

• Place client on bedrest and administer sedation as ordered

• Advise client to avoid coitus

• Avoid vaginal exam• Assist with ultrasound• Administer IV pitocin,

analgesics, blood products as ordered

• Save all passed tissue

• Assist with D&C• Administer antibiotics

and RhoGam as ordered


• Ectopic pregnancy– Abnormal implantation outside the uterus– Implantation in the fallopian tube tubal

rupture fatal hemorrhage– Risk factors include any factor that

compromises tubal patency (PID, IUD > 2 yrs)– Transvaginal US shows empty uterus– S/S – unilateral stabbing pain, vaginal

spotting, referred shoulder pain, nausea, vomiting, and shock

Ectopic Pregnancy

• Assess for unilateral pain and vaginal bleeding• Assess vital signs • Asses skin color and urine output• Provide replacement fluid and maintenance of

electrolyte balance• Provide education and psychological support• Prepare client for surgery: linear salpingostomy

(helps to salvage fallopian tube if not ruptured) and laparoscopic salpingostomy (tube removal)

Complications of Pregnancy• Gestational trophoblastic disease

– Proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid filled, and “grape like”

– Complete mole – all genetic material is paternally (father) derived and contains no fetus, placenta, amniotic membranes, or fluid

– Partial mole – genetic material is derived both maternally (mother) and paternally and contains abnormal embryonic or fetal parts, an amniotic sac, and fetal blood

Molar Pregnancy

Gestational Trophoblastic Disease

• Risk factors include: low protein intake, < 18 years of age, > 35 years of age

• Ultrasound will reveal dense growth with characteristic vesicles, but no fetus in utero

• S/S – rapid uterine growth, vaginal bleeding, discharge, excessive vomiting, PIH, elevated hCG

• Measure fundal height, assess bleeding, assess GI status and appetite, check VS, assess edema

• May have suction curettage for mole evacuation


• Incompetent cervix– Painless, passive dilation of the cervix in the

absence of uterine contraction– Usually occurs around 20 weeks of gestation– Cervix cannot support the weight and

pressure of the fetus and results in expulsion– Risk factors include cervical trauma, in utero

exposure to DES, congenital structural defects, and increased maternal age

Incompetent Cervix• Ultrasound will show short cervix, < 20 mm in

length, which indicates cervical incompetence• S/S – bleeding pelvic pressure, rupture of

membranes, uterine contractions, uterine pressure

• May have cervical cerclage, a surgical procedure that uses heavy ligature to strengthen the cervix

• Place client on bedrest; tocolytic medications• Client must avoid intercourse, prolonged

standing, and heavy lifting

Cervical Cerclage


• Placenta previa– Occurs when the placenta abnormally

implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus

– Results in bleeding during the 3rd trimester as cervix dilates and effaces

– Major complications associated with placenta previa are: maternal hemorrhage, and fetal prematurity or death

Placenta Previa

• 3 types: – Complete or total – when the cervical os is

completely covered by the placental attachment

– Incomplete or partial – when the cervical os is only partially covered by the placental attachment

– Marginal or low-lying – when the placenta is attached in the lower uterine segment but does not reach the cervical os

Placenta Previa

Placenta Previa• Risk factors include: previous placenta previa,

uterine scarring, maternal age > 35 years, multifetal gestation, multiple gestations, or closely spaced pregnancies

• Diagnosed with transabdominal or transvaginal ultrasound which shows placental placement

• S/S – painless, bright red vaginal bleeding, relaxed, nontender uterus with normal tone, higher than expected fundal height, palpable placenta, fetus in breech, oblique, or transverse position

Placenta Previa• Assess bleeding, leaking, or contraction• Count pads for bleeding amount• Examine the abdomen, and assess fundal height• Perform Leopold’s maneuvers to determine fetal

position and presentation• Check VS and assess I&O• Place client on bedrest, IV fluids as ordered,

blood replacement as ordered• Nothing inserted vaginally• Corticosteroids given for fetal lung maturation


• Abruptio placenta– Premature separation of the placenta from the

uterus– Can be partial or complete detachment– Occurs after 20 weeks gestation, usually in the

3rd trimester– Leading cause of maternal death– Moderate to severe abruption disseminated

intravascular coagulopathy (DIC) – Associated with maternal hypertension

Abruptio Placenta

Abruptio Placenta• Associated with abdominal trauma, cocaine

abuse, prior history of abruption, smoking, premature rupture of membranes, short umbilical cord, and multifetal pregnancy

• Diagnosed with ultrasound to determine fetal well-being and placental placement

• S/S – sudden onset of intense localized uterine pain, vaginal bleeding, board-like abdomen, firm rigid uterus with contractions, fetal distress, hypovolemic shock

Abruptio Placenta• Palpate the uterus for tenderness and tone• Assess bleeding rate, amount, and color• Assess fetal heart rate, maternal VS, maternal

color and turgor, maternal capillary refill, urine output, and LOC

• Place client on bedrest, refrain from vaginal exams

• Administer blood products, fluid volume replacement, corticosteroids, and immune globulin as ordered

• Treatment: cesarean delivery


• Hyperemesis gravidarum– Excessive nausea and vomiting, related to

elevated hCG levels, that is prolonged past 12 weeks gestation and results in 5% weight loss from nonpregnancy weight, dehydration, electrolyte imbalance, ketosis, and acetonuria

– May be accompanied by liver dysfunction– Risk to fetus for intrauterine growth restriction

or preterm birth

Hyperemesis Gravidarum

• Risk factors include: mother < 20 years, obesity, 1st pregnancy, multifetal gestation, gestational trophoblastic disease, history of psychiatric disorders, transient hyperthyroidism, vitamin B deficiencies, high stress levels

• Diagnostics include: UA for ketones and acetones, elevated specific gravity, chemistry profile, elevated liver enzymes, thyroid test, and elevated Hct

Hyperemesis Gravidarum• S/S – excessive vomiting, dehydration with

possible electrolyte imbalance, weight loss, decreased B/P, increased P, poor turgor

• Monitor I&O, skin turgor, mucus membranes, VS, and weight

• NPO for 24-48 hours, advancing to clear liquids after 24 hours if no vomiting, advancing to diet as tolerated, TPN in severe cases

• IV fluids of lactated Ringer’s solution, vitamin B6 and other supplements, antiemetic and corticosteroids

Complications of Pregnancy• Gestational hypertension (GH)/Pregnancy

induced hypertension (PIH)– Gestational hypertensive diseases are

associated with placental abruption, ARF, hepatic rupture, preterm birth, and fetal and maternal death

– High risks include: mother < 19 years or > 40 years old, 1st pregnancy, morbid obesity, multifetal gestation, CRF, chronic HTN, diabetes, Rh incompatibility, molar pregnancy, previous GH

Gestational Hypertension/Pregnancy Induced Hypertension

• Diagnostics include: dipstick urine testing for proteinuria, 24 hour urine collection for protein and creatinine clearance, liver enzymes, serum creatinine, BUN, uric acid, magnesium, CBC, clotting studies, chemistry profile, nonstress test, and doppler blood flow analysis

• Vasospasm poor tissue perfusion s/s of pregnancy hypertensive disorders

• S/S – severe headache, visual changes, sudden edema or swelling, rapid weight gain, epigastric pain


• Gestational hypertension– Begins after the 20th week of pregnancy– Woman has B/P of 140/90 or >, or systolic

increase of 30 mm Hg or a diastolic increase of 15 mm Hg from prepregnancy baseline

– No proteinuria or edema– Returns to baseline by 6 weeks postpartum– Associated with uteroplacental insufficiency

due to vasospasm, rupture of the liver, and intrauterine growth restriction


• Mild preeclampsia– Begins after the 20th week of pregnancy– Woman has B/P of 140/90 or >, or systolic

increase of 30 mm Hg or a diastolic increase of 15 mm Hg from prepregnancy baseline

– 1+ to 2+ proteinuria– Weight gain of > 2 kg (4.4 lb) per week in

the second and third trimesters


• Severe preeclampsia– Begins after the 20th week of pregnancy– Woman has B/P is 160/100 mm Hg or >, 3+ to

4+ proteinuria– Oliguria, elevated serum creatinine > 1.2

mg/dL, headache, blurred vision, hyperreflexia with possible ankle clonus

– Pulmonary and cardiac involvement, peripheral edema, hepatic dysfunction, epigastric and RUQ pain, thrombocytopenia


• Eclampsia– Begins after the 20th week of pregnancy– Woman has B/P is 160/100 mm Hg or >, 3+ to

4+ proteinuria– Oliguria, elevated serum creatinine > 1.2

mg/dL, headache, blurred vision, hyperreflexia with possible ankle clonus

– Pulmonary and cardiac involvement, peripheral edema, hepatic dysfunction, epigastric and RUQ pain, thrombocytopenia, seizures or coma


• HELLP syndrome is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction– H – hemolysis anemia and jaundice– EL – elevated liver enzymes (AST, ALT),

epigastric pain, nausea and vomiting– LP – low platelets thrombocytopenia,

abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly DIC


• Monitor B/P, observe for edema, check DTRs, assess FHR for variability and decelerations

• Monitor respirations, LOC, pulse oximetry, urine output, daily weights, and VS

• Maintain bedrest in side-lying position• Avoid foods high in sodium, alcohol, and limit

caffeine• Hyperreflexia and epigastric pain = seizures• Encourage fluids; antihypertensive medications• Seizure precautions, dark quiet environment


• Administer IV magnesium sulfate, the medication of choice as an anticonvulsant agent for prophylaxis or treatment

• Magnesium sulfate will lower blood pressure and depress the CNS

• Magnesium sulfate toxicity includes: absence of patellar DTRs, urine output < 30 mL/hr, respirations < 12/min, decreased LOC

• If magnesium toxicity is suspected: D/C medication, administer calcium gluconate (antidote), and prevent respiratory or cardiac arrest


• Gestational diabetes– An impaired tolerance to glucose with the first

onset or recognition during pregnancy– Ideal blood glucose 60-100 mm/dL– Symptoms may disappear a few weeks

following delivery– Approximately 50% of women develop DM

within 5 years– Risk factors include: mother > 30 years,

obesity, family history of diabetes, stillborn

Gestational Diabetes• Insulin acts like growth hormone on the fetus• Increased fetal risks including: spontaneous

abortion, infections, hydramnios (excess amniotic fluid), ketoacidosis, hypoglycemia, and hyperglycemia

• Maternal risk of: urinary tract infections due to glycosuria, and ketoacidosis

• Diagnostics include: urinalysis with glycosuria, 1 and 3 hour GTT, urine ketones, BPP, amniocentesis with AFP, nonstress test

Gestational Diabetes

• S/S – hunger and thirst, frequent urination, blurred vision, excess weight gain during pregnancy

• Monitor blood glucose; monitor fetus• Teach s/s of hypoglycemia and hyperglycemia• Educate about diet and exercise• Administer insulin and teach self administration• Oral hypoglycemic medications contraindicated• Instruct client to perform “daily kick counts”

Healthcare During Pregnancy• Prenatal period is the period between

conception and onset of labor• Regular prenatal care is associated with lower

infant mortality and better child outcomes• Goals of good prenatal care:

– Promote physical and mental wellness of the mother during pregnancy and afterward

– Help the woman give birth safely and without complications

– Ensure a healthy baby

Healthcare During Pregnancy

• Components of prenatal care: early and regular prenatal care, maintenance of maternal health; promotion of good habits, and recognition and treatment of physical, mental, social, and economic problems

• Risk assessment identifies women and fetuses who have a chance of having a complication during pregnancy, birth, or the neonatal period


• Prenatal visits: – Every 4 weeks for the 1st 28 weeks– Then every 2 weeks until 36 weeks– Then weekly until birth

• The postpartum visit is usually scheduled at 4 to 6 weeks after birth

• Some providers like to see the woman at 2 weeks postpartum


• Initial prenatal visit– Establish schedule of prenatal visits– Health history – past illnesses, inherited

diseases, multifetal pregnancy, previous difficulties during pregnancy, serious infections, STDs, or HIV

– Physical exam – pelvic examination and measurements, head-to-toe assessment, height, weight, PAP test, and STD tests

– Laboratory tests – blood type and Rh factor


• Initial prenatal visit– Other tests – VDRL, CBC, antibody screen,

and rubella titer– HIV testing – should be offered– Pregnancy test and urine test for albumin,

glucose, and bacteria– PPD tuberculin skin test– Genetic counseling and testing if indicated– Determining the baby’s due date


• A full term pregnancy is approximately 280 days from the first day of the last menstrual period (LMP), or 266 days after fertilization

• Determining the estimated date of delivery (EDD); also called the estimated date of confinement (EDC), uses Nagele’s Rule– Determine the date of the 1st day of the

woman’s LMP, add 7 days, subtract 3 months, the resulting date is the EDD


• Return prenatal visits– Following measures should be performed:

weight, B/P, urine “dipstick”, measure of fundal height, fetal heart tones, checking for edema, and continuing risk assessments

– Ultrasound between 16-20 weeks to determine gestational age

– Maternal serum alphafetoprotein (MSAFP) test between 5-19 weeks to screen for fetal neural tube defects

Fundal Height

Fundal Height

• The fundal height is measured in centimeters and equals the approximate gestational age in weeks, until week 32

• Fundal height:– 12 weeks – 12 centimeters– 16 weeks – 16 centimeters– 20 weeks – 20 centimeters– 24 weeks – 24 centimeters


• Return prenatal visits– Triple marker screen – the MSAFP may be

combined with 2 other tests (HCG and estriol) which increases the number of neural tube defects that may be identified and also screens for Down syndrome

– Between 24-28 weeks all women should be screened for diabetes using a 1 hour random glucose tolerance test


• Return prenatal visits– The Rh antibody test is repeated at 26

to 27 weeks, and RhoGam is given at 28 weeks if the antibody test remains negative

– Many providers repeat STD testing at 36 weeks, and may also do a vaginal culture for group B streptococcus


• Elimination and hygiene– Daily bowel movement is preferred– More active oil and sweat glands so daily bath

is important– May experience ptyalism – increase in saliva

• Breast care– Supportive bra– Elaborate breast care unnecessary, little or no

soap on the nipples


• Rest– During the last months of pregnancy the

woman should rest on her left side for at least 1 hour in the morning and afternoon to relieve fetal pressure

– Avoid sleeping or lying on the back due to supine hypotension syndrome due to fetal compression on the aorta and the vena cava

– If woman must remain on back, place small pillow or towel roll under one hip

Aortocaval Compression


• Exercise, posture, and activity– Exercise improves circulation, appetite, and

digestion– Exercise should be daily, rather than sporadic

• Sexual relations– Sexual response cycle is affected by

pregnancy– Touch needs, comfort and reassurance needs

continue

Sexual Safety

• Women who experience bleeding should avoid vaginal penetration

• Sex with a partner who has STDs, or sex after rupture of membranes increase risk of infection

• Sexual arousal may initiate labor for a woman at risk for preterm labor

• Orgasm stimulates uterine contractions• Blowing air into the vagina increases risk of air

embolism


• Clothing– Need for looser clothing, use of flat heels– May have trouble typing laces or fastening

buckles– Wide strapped bra for support

• Travel and employment– Use seat belts and shoulder straps– Never fly in small non pressurized plane– Avoid risky jobs: radiation, toxins, standing


• Teratogens are substances known to cause fetal defects– Diseases – Rubella, herpes, toxoplasmosis,

syphilis– Medications – phenytoin, lithium, valproic

acid, isotretinoin, and warfarin– Substances of abuse – tobacco, alcohol,

heroin, cocaine– Ionizing medication

Fetal Alcohol Syndrome

• Alcohol crosses the placental barrier and cause: growth deficiency, craniofacial deformity, behavioral and cognitive impairment, motor and sensory deficits, and seizures

Nutrition During Pregnancy

• Adequate nutrition to support the mother and the growing fetus– Increase milk and milk products– Increase calories by 300/day– Increase iron, folic acid, and most vitamins– Reduce empty calories– Use iodized salt– Avoid laxatives and enemas– Increase fluid to 10 glasses/day

Nutrition During Pregnancy

• Changes in the woman’s body during the early part of pregnancy may interfere with appetite

• Caffeine can be harmful to pregnant women contributing to mastitis, and cross the placenta causing irritability in the fetus– Avoid coffee, some teas, most colas and

other soft drinks, and chocolate• Pica – abnormal craving for nonfood items

such as clay, dirt, or cornstarch

Weight Gain During Pregnancy

• Recommended weight gain during pregnancy is usually 25-35 pounds

• General rule: weight gain of 3-4 pounds the first trimester, and 1 pound per week for the last 2 trimesters

• Excessive weight gain macrosomia (big baby) and labor complications

• Poor weight gain low birth weight

Adapting to Pregnancy• 1st trimester: weeks 1-13

– Acceptance of the pregnancy– May exhibit ambivalence, shock, disbelief, self-

focus, and fear• 2nd trimester: weeks 14-27

– Incorporate fetus into maternal body image– May exhibit dependency, excitement,

calmness, increased libido• 3rd trimester: week 28-terms

– Sees the fetus as separate from self

Prenatal and Childbirth Education

• 1st trimester teaching:– Physical and psychosocial changes– Discomforts of pregnancy and relief measures– Lifestyle: exercise, stress, nutrition, sex,

dental care, medication use, substance abuse, and STDs

– Complications, choosing an obstetrician – Fetal growth and development– Prenatal exercise, laboratory testing


• 2nd trimester teaching:– Planning to breast or bottle feed– Common discomforts and relief measures– Lifestyle: sex and pregnancy, rest and

relaxation, posture, body mechanics, clothing, seat best safety, and travel

– Fetal movement (quickening)– Complications– Childbirth preparation


• 3rd trimester teaching:– Birth plan– Breathing and relaxation techniques– Decisions about pain management– Signs and symptoms of labor– Labor process– Infant care– Postpartum care– Fetal movement/kick counts

Common Discomforts• Nausea and vomiting – should eat crackers or

dry toast ½ to 1 hour before rising• Breast tenderness – bra that provides support• Urinary frequency – 1st and 3rd trimesters• Urinary tract infections – wipe front to back,

unscented toilet tissue, cotton underpants, 8 glasses of water, eat yogurt and acidophilus milk, urinate after intercourse

• Fatigue – frequent rest periods• Heartburn – small frequent meals• Constipation – increase fluids, fiber, exercise

Common Discomforts• Hemorrhoids – warm sitz bath or witch hazel

pads• Backaches – regular exercise, pelvic tilts, proper

body mechanics• Shortness of breath and dyspnea – good

posture, extra pillows, avoid overeating• Leg cramps – extend leg and dorsiflex foot• Varicose veins and lower extremity edema –

elevate legs, support hose, avoid sitting or standing for prolonged periods

Common Discomforts

• Gingivitis, nasal stuffiness, and epistaxis – gently brush teeth, good dental hygiene, humidifer, and normal saline nose drops or spray

• Braxton-Hicks contractions – change of position and walking– Report increase in intensity and frequency

• Supine hypotension – lay in side-lying or semi-sitting position with knees slightly flexed

Common Birthing Methods

• Dick-Read method – refers to “childbirth without fear”, uses controlled breathing, and relaxation

• Lamaze – focuses on partner-coached breathing, relaxation with panting, and outside focal points

• Leboyer – refers to “birth without violence”, dim lights, soft voices, warm room

• Bradley – stresses partner’s involvement, natural childbirth, breathing techniques, relaxation

Documents

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