Nursing Management During Pregnancy

implicit bias

-attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner

-impact:

• diagnostic uncertainty

• poorly rated clinical interactions

• less pt-centeredness

• poor provider-pt comunication

• undertreatment of pain

• poorer health outcomes

first visit when missed menstrual cycle occurs

-ideally preconception counseling is recommended but not always

-often called “amenorrhea visit”

-urine pregnancy test

-HCP will use Naegle’s rule to approximate estimated date of confinement (EDC) or estimated date of delivery (EDD)

-explore pt’s feelings about information given

-pt then scheduled for an ultrasound to confirm

naegle’s rule

add 7 days to the first date of LMP, then add 9 months and adjust year if needed to approximate EDC or EDD

first prenatal visit

-establish a trusting relationship

-demographics: family support

-obstetrical/gyneocological history: first day of LMP, gravidity and parity

-current pregnancy: EDC or EDD, make sure ultrasound aligns with it

-medical history: allergies, immunizations (can’t have live vaccines during pregnancy), STI history

-comprehensive physical exam: VS, height, weight, nutrition

gravida

number of pregnancies, including current, regardless of outcome

gravida 1

primigravida

-first pregnancy

gravida 2

secundigravida

-second pregnancy

para

number of births 20 weeks of gestation of greater

primipara

one birth after a pregnancy of at least 20 wks

multipara

2+ pregnancies resulting in viable offspring

nullipara

no viable offspring; para 0

term

offspring 37-42 wks

preterm

offspring 20-36.6 wks

abortion

early losses of fetus prior to 20 weeks

living children

currently living offspring

pelvic examination

-examination of external and internal genitalia

-bimanual examination

-pelvic shapes: gynecoid, android, anthropoid, platypelloid

-collect samples: pap smear if needed, GC/CT, and trich

urinalysis

urine sample collected every visit

CBC

blood draw collected first visit, 24-28wks (assessing for anemia)

blood typing

A, B, AB, or O type; positive or negative

Rh factor

if pt has negative Rh factor, they will need rhogam at 28 wks and up to 72 hrs after delivery or if trauma has occured

-if mom is negative and fetus is negative, rhogam is not given

-if mom is negative and fetus is positive, rhogam is given to ensure incompatibilities don’t occur in the future and cause hemolytic anemia

rubella titer

if titer is 1:8 or less, mom is not immune

hepatitis B surface antigen

determines if pt is immune or hep B positive

HIV, VDRL, and RPR testing

needs treatment if positive, tested more frequently

-conducted at first visit at 37 wks

cervical smears

if abnormal pap smear will intervene after delivery

-GC/CT, trich but group B strep at 37 wks (collected at end of pregnancy bc values are accurate for only 5 wks)

ultrasound

conducted during first trimester then 18-20 wk anatomy scan to see if organs have developed

HbA1C

if pt has risk factors during first visit it is conducted, otherwise at 24-48 wks and 6 wks postpartum with glucose test

group B streptococcus

cervical sample collected at 36 wks to determine if the pt needs antibiotics during labor

recommended immunizations

-hepatitis B

-influenzae (inactivated) injection

-tetanus/diphtheria (Tdap)

-Rabies

contraindicated immunizations

-influenzae (live, attenuated) nasal spray

-measles/mumps/rubella

-varicella

-BCG (tuberculosis)

-typhoid

frequency of visits

-continuous prenatal care is important for a successful pregnancy outcome

-the recommended follow-up visit schedule for a healthy pregnant women:

• every 4wks up to 28wks

• every 2 wks from 29-36 wks

  • every wk from 37 wks-birth

-high risk pt have more frequent visits

prenatal assessment

-conducted at each prenatal visit:

• weight and BP (compared with baseline values)

• urine testing for protein, glucose, ketones, and nitrates

• fundal height to assess fetal growth

• assessing for quickening to determine fetal well-being

• assessment of fetal heart rate (110-160 bpm)

assessment of fetal growth

-measured via tape measure, starting at 20 wks gestation, from pubic symphysis to the fundus

• fundus: top part of uterus, hard/firm upon palpation

-fundal height indicates/should correlate with gestational wk

over

if the fundal height is 2-3 cm _ the expected gestational wk, the abdominal cavity is too large, the fetus is abnormally large, pr polyhydramnios could be the cause

-anatomy scan should be conducted

less

if the fundal height is 2-3cm _ than the expected gestational wk, cause could be IUGR, nutritional deficiencies, or abnormal growth

-anatomy scan should be conducted

first trimester danger signs

-bleeding (can be normal)

-painful urination

-severe/or persistant vomiting (concern for hyperemesis gravida and nutrition)

-lower abdominal pain

-dizziness accompanied by shoulder pain (concern for gallbladder disease)

second trimester danger signs

-regular uterine contractions (every 2-3 mins)

-calf pain

-sudden gush of fluid

-no fetal movement approximately 29 wks and beyond 12 hrs

third trimester danger signs

-sudden weight gain (concern for preeclampsia)

-periorbital or facial edema (concern for preeclampsia)

-severe upper abdominal pain or HA with vision changes (concern for preeclampsia)

-decrease in fetal daily movement to more than 24 hrs

serum for genetic testing

-alpha-fetoprotein analysis (15-20 wks)

• recommended for pt 35yrs+

-marker screening tests (quad screen, PAP-A; 15-20wks)

diagnostic genetic tests

-doppler flow studies (starting at 28 wks); for high risk pt for IUGR

-nuchal translucency screening (11-14wks)

• looks for thickness behind head and spine

-amniocentesis (15-20 wks)

• confirmation for screening test

• risk for miscarriage and defects

-chorionic villus sampling (10-13 wks)

• confirmation for screening tests

• risk for miscarriage and defects

-percutaneous umbilical blood sampling (PUBS)

-nonstress test

-contraction stress test

-biophysical profile

nonstress test (NST)

evaluates fetal well-being through fetal heart rate reactivity

-performed after 28 wks gestation in presence of maternal risk factors

-pt is placed on EFM in semi-fowler’s or side lying position given an event marker and told to press it whenever fetal movement is felt

-takes 20-30 mins

-a reassuring NST is desired: normal FHR baseline, average variability (6-25), 2 or more accelerations over a 20 minute period

-have patient eat something before test to encourage fetal movement

contraction stress test (CST)

observes fetal response to the stress of uterine contractions

-provides early warning of fetal compromise (hypoxia, asphyxia)

-performed at full term in the presence of maternal risk factors and/or non-reactive NST
-pt is placed on fetal monitor for 20-30 mins

-uterine activity (3 contractions within 10 mins) is elicited through nipple stimulation or IV oxytocin fusion

-a negative CST is desired: no late decelerations with contractions within 10-15 min period

biophysical profile (BPP)

evaluates fetal well-being by assessing five markers

-each criteria is scored as present (2pts) or non present (0pts)

• 8-10/10: reassuring

• 6/10: equivocal or suspicious

• 4 or less/10: nonreassuring

-Acute markers: fetal tone, gross fetal movements, fetal breathing movements, fetal heart reactivity

-Chronic marker: amniotic fluid volume

-all markers except fetal heart reactivity are assessed via ultrasound

first trimester discomfort

-urinary frequency or incontinence

-fatigue (encourage rest periods, not bedrest)

-N/V

-breast tenderness

-constipation

-nasal stuffiness, bleeding gums, epistaxis

-cravings

-leukorrhea

second trimester discomforts

-backache

-varicosities of vulva and legs

-hemorrhoids

-flatulence with bloating

third trimester discomforts

-return of first trimester discomforts

-SOB and dyspnea

-heartburn and indigestion

-dependent edema

-Braxton hicks contractions

preparation for birth

-education:

• perineal care

• childbirth

• lamaze

• bradley

• dick-read

-options for birth setting:

• hospitals

• birth centers

• home birth

-options for care providers:

• obstetrician

• midwife

• doula

-feeding choices:

• breast feed: decrease risk for infection, feed on demand, cost-effective; ensure enough nutrients and encough breast milk for feedings

• formula feed: newborn sleeps longer and stays fuller; costly and correct prep

-final preparation for labor and birth

lamaze method

focus on breathing and relaxation technique

bradley method

-partner-coached childbirth

-focus on exercises and slow, controlled abdominal breathing

dick-read method

-natural childbirth

-focus on fear reduction via knowledge and abdominal breathing techniques

-no medications (typically)

promoting self-care

-personal hygiene

-avoid saunas and hot tubs

-perineal care

-dental care

-breast care

-clothing (not tight-fitting)

-exercise (light impact/contact)

-sexuality and sexual activity

-employment

-travel

-immunizations and meds

-sleep and rest