Prenatal Assessment, Health promotion & Nutrition- Ch 10-12

What are the initial prenatal visit: history & risk assessment?

• Pregnancy history

  • LMP / dating

  • Prior pregnancies & outcomes

  • Fertility treatment / prior loss

• Health history

  • Medical / surgical history

  • Medications, supplements, allergies

  • Family / genetic history

• Exposure & safety

  • Substance use

  • Infection / travel / occupational risks

  • IPV and personal safety → intimate partner violencw (higher risk)

• Social context

  • Food, housing, transportation

  • Work / caregiving demands

  • Supports, mental health, access to care

• Nursing habit: ask without judgment → identify risk → connect to resources → document clearly

What are the baseline assessments that becomes comparsion point?

• Maternal baseline

  • Blood pressure

  • Weight / prepregnancy BMI context

  • Focused physical assessment

  • Mental health / safety / social needs

  • Symptoms & current concerns

• Pregnancy baseline

  • Confirm dating

• Fetal viability / heart rate as appropriate

  • Review prior imaging / results

  • Establish gestational-age–specific expectations

• Why it matters later

  • Is BP rising from baseline?

  • Is weight gain on an appropriate trajectory?

  • Is uterine growth consistent with gestational age?

  • Are new symptoms expected or concerning?

  • Has psychosocial risk changed?

• “What finding today will matter when I compare it with a later visit?

• Fundus: 12 weeks just rising above symphis pubis,14 weeks half way, 20 weeks at umbilicus, 36+ at zyphoid process

What are the routine initial prenatal labratory screening?

• ABO / Rh + antibody screen: Transfusion compatibility; identify Rh-negative patients and existing alloantibodies

  • Rh immune globulin (brand name RhoGAM) is given at 28 weeks and after they deliver baby if thier blood type is positive (also if trauma or miscarrige occurs)

• CBC: Screen for anemia and establish hematologic baseline

  • can have physiologic hemodilution

• Urinalysis / urine culture: Identify bacteriuria / infection and establish baseline

• Rubella immunity: Identify susceptibility; live vaccine is given postpartum, not during pregnancy

  • Rubella: german measels, can cause blindness to babies if Mom contracts during prgnancy

• Hepatitis B & C, HIV, syphilis: Identify infection and guide treatment / perinatal prevention

  • Immunoglobin and vaccine given if Mom is positive (to baby after birth)

• Other testing as indicated: STIs, TB, genetic carrier screening, immunity or disease-specific tests based on history/risk

Rh status & antibody screen

• Rh-negative patient

  • Identify maternal blood type / Rh status → Antibody screen Is the patient already sensitized? → Rh(D) immune globulin Prevent sensitization when indicated

• An unsensitized Rh-negative patient may receive Rh(D) immune globulin around 28 weeks

  and after potential fetomaternal blood exposure / birth when indicated

What does ongoing prenatal care include?

• At routine visits, think…

  • Maternal status: BP symptoms, weight trajectory

  • Fetal status: FHR, growth, movement when appropriate

• Results: Review labs / imaging / screening

• Teaching: What is next? What should prompt a call?

• Access: Mental health, safety, resources, barriers

• Traditional schedules are familiar, but current guidance emphasizes individualized prenatal care delivery.

  • Higher-risk findings → more surveillance

  • Some routine care may be delivered through tailored in-person / virtual approaches

  • The purpose of surveillance matters more than memorizing visit intervals

What is the routine surveillance of fetal growth & well being?

• Fetal heart rate:

  • Assess as appropriate to gestational age and setting

  • Routine fetal status

• Fundal height

  • Primary screening tool for fetal growth after ~24 weeks

  • Growth trend

• Fetal movement

  • Teach awareness of the patient’s usual pattern later in pregnancy

  • Patient-reported well- being

• Ultrasound

  • Dating, anatomy, placental location, growth or other indications

  • Structural / growth information

• Abnormal growth, decreased movement, or concerning maternal symptoms → evaluate rather than “watch and wait.”

What are the prenatal testing & teaching milestones?

• Women are offered screenings but it is up to the individual

• GBS- group beta strep; can change so prevent baby being exposed as being delivered → normal part of microbiome but can be harmful to baby if they are exposed during birth thus why its tested for late and treated with antibiotics during labor to prevent exposure

Screening v diagnostic testing

• Screening; estimates risk/probability

  • Does not confirm a diagnosis

  • May be blood-based, ultrasound-based, or combined

  • A positive result requires counseling and may lead to diagnostic testing

  • Patient may accept or decline after informed discussion

• Diagnostic; Answers a more specific question, definitively diagnose abnormality

  • CVS or amniocentesis can diagnose many chromosomal/genetic conditions

  • Invasive tests have benefits, limits, and procedure- related risks

  • Results may affect pregnancy management and preparation

  • Nursing role: clarify, support, avoid directing the patient’s choice

• Sceening ≠ diagnosis

What are the prenatal genetic screening?

• Screen; cfDNA / NIPT- Most sensitive/specific common screening test for common aneuploidies; can begin around 10 weeks

• Screen; First-trimester / serum approaches Estimate risk using blood tests ± ultrasound depending on approach

• Screen / Image; Second-trimester anatomy ultrasound Structural assessment; ideally 18–22 weeks

• Diagnostic; CVS Diagnostic procedure typically 10–13 weeks → sample of placenta

• Diagnostic; Amniocentesis Diagnostic procedure typically from ~15 weeks

How is health promoted in pregnancy?

• Move: For uncomplicated pregnancy: aim for ≥150 min/week moderate-intensity aerobic activity

• Protect: Seatbelt low across hips + shoulder belt; avoid overheating / high-risk activities

• Sleep / position Comfort strategies; later pregnancy may favor side-lying when symptomatic

• Oral health: Routine dental care and oral hygiene remain important → oral issue will affect overall health (infection in mouth can get into heart)

• Work / travel: Individualize around symptoms, exposures, mobility, and pregnancy risk

• Mental health: Screen routinely; normalize help-seeking and connect to care

What are the medications, OTC, supplement & substance safety?

• Medication safety

  • Review prescriptions, OTC products, herbals, and supplements at every transition

  • “Natural” does not mean pregnancy-safe

  • Do not advise abrupt discontinuation of a necessary prescription without prescriber guidance

  • Check the current plan when nausea, reflux, pain, allergies, or infection prompts OTC use

• Substance screening

  • Ask about alcohol, nicotine/vaping, cannabis, and other substances without judgment

    • FASD can occur with alcohol consumption in pregnancy

  • Use clear language: no known safe amount of alcohol during pregnancy

  • Assess readiness, safety, withdrawal risk, and supports

  • Connect to treatment and harm-reduction resources when needed

• Never let shame become a barrier to disclosure or care

What are the vaccines during pregnancy: protect parent + newborn?

• Influenza; Inactivated / recombinant influenza vaccine during pregnancy; live nasal vaccine is contraindicated- Seasonal

• Tdap; Recommended during every pregnancy; preferably early in 27–36 weeks- Each pregnancy

• Maternal RSV (Abrysvo); 32 0/7–36 6/7 weeks, seasonally Sep–Jan in most of continental U.S.- Seasonal + gestational

• Live vaccines; MMR and varicella are contraindicated during pregnancy; vaccinate postpartum when indicated- Avoid in pregnancy

Nutrition in pregnancy

• Start with the plate; Build meals around

  • Protein-rich foods

  • Whole grains / high-fiber carbohydrates

  • Fruits and vegetables

  • Calcium-rich foods

  • Healthy fats + hydration

• Energy needs

  • For many patients entering

  • pregnancy at a healthy weight:

  • 1st trimester

  • Usually no extra calories

  • 2nd trimester

  • ~+340 kcal/day

  • 3rd trimester

  • ~+450 kcal/day

• Individualize

  • Nausea / vomiting

  • Food insecurity

  • Cultural preferences

  • Vegetarian / vegan diets

  • Adolescence or multiple gestation

  • Diabetes / bariatric surgery / other conditions

• Also wants to increase ater and food intake in breast feeding

**What is the expected weight gain; start with prepregnancy BMI?**

• Use the range as a counseling guide—not a judgment.

• Underweight: <18.5

  • 28–40 lb

• Healthy weight: 18.5–24.9

  • 25–35 lb

• Overweight: 25.0–29.9

  • 15–25 lb

• Obesity: ≥30

  • 11–20 lb

• Nursing focus: trend weight + nutrition + fetal growth together; avoid shame-based counseling.

What are the high- yield nutrients & supplements to support pregnancy?

• Folic acid: ≥400 mcg/day before and during early pregnancy for most people

  • Neural tube development ex. myelomeningocele; spina bifida

• Iron: Pregnancy need ≈27 mg/day

  • Maternal RBC expansion / fetal needs

• Calcium: Support maternal bone health + fetal skeletal development

  • Bone / neuromuscular function

• Vitamin D: Supports calcium metabolism and bone health

  • Bone / immune function

• Choline: Pregnancy target ≈450 mg/day

  • Fetal brain / nervous system

• Iodine / B12 / omega-3s: Assess diet pattern and prenatal vitamin content

• May need individualized attention

What is the food safety for fish, caffeine & alcohol with pregnancy?

• Food Safety

  • Avoid unpasteurized milk/cheese and raw or undercooked animal foods

  • Heat deli meats / hot dogs until steaming hot

  • Wash produce and avoid cross-contamination

• Seafood

  • Choose lower-mercury fish

  • Aim for 8–12 oz/week from recommended choices

  • Avoid high-mercury fish → swordfish, tuna, macral

• Caffeine

  • Keep intake <200 mg/day

  • Count coffee, tea, energy drinks, soda, chocolate, medications

• Alcohol

  • No known safe amount or safe time during pregnancy

  • Use nonjudgmental screening and support

What are the warning signs in pregnancy?

• Bleeding or fluid leakage; Vaginal bleeding • gush / persistent trickle of fluid

  • Can have bleeding in early pregnancy (implantation bleeding) and after coitus → but should still check with provider bc it may not be normal

• Neurologic / BP symptoms; Severe headache • visual changes, fainting

• Pain / contractions; Severe abdominal or pelvic pain, regular painful contractions before term

• Respiratory / clot symptoms; Chest pain, dyspnea at rest, unilateral leg swelling/pain

• Infection / hydration: Fever, dysuria with systemic symptoms, persistent vomiting / dehydration

• Fetal concern: Decreased fetal movement once a usual pattern is established → when baby gets bigger less space to move, or baby is asleep can mean no fetal movement but should be able to wake baby up by giving sugar, sitting down after standing and walking for a while; if not need it is of concern and to notify provider

• Patient teaching language: “This can be common, AND call us right away if…”