OB Exam 2 Chapter 12: nursing management during pregnancy

Pre-conception care

prior to conception

interconception care

between pregnancies

goal of Preconception and Interconception Care

Prevent adverse pregnancy outcomes

focus of Preconception and Interconception Care

General health status of both partners

Preconception and Interconception Care: areas addressed

-Reproductive planning

-Physical exam

-Personal and family history

-Lab screening

-Nutritional status/weight/exercise

-Vaccines (flu, rubella, varicella, DPT)

-Assess teratogen exposure

-Folic acid intake of 400 - 800 mcg/day (per risk profile)

-Others

risk factor for adverse pregnancy outcomes: accutane

-Serious birth defects

-for current use not prior use

-especially teens and early 20's

risk factor for adverse pregnancy outcomes: alcohol misuse

Fetal alcohol syndrome.

NO safe time for alcohol in pregnancy

risk factor for adverse pregnancy outcomes: Antiepileptic meds. (Valporic acid)

Teratogenic

risk factor for adverse pregnancy outcomes: Diabetes (preconception)

3-fold increase in birth defects in those with Type 1 or Type 2 Diabetes if not well managed

risk factor for adverse pregnancy outcomes: folic acid deficiency

Associated with NTD's (neural tube defects)

risk factor for adverse pregnancy outcomes: HIV/AIDS

Antiretroviral treatment (significantly reduces risk to baby)

**catch early

risk factor for adverse pregnancy outcomes: STI's

-Chlamydia and Gonorrhea .. Associated with ectopic pregnancy and infertility

-Other STI's may be associated with intellectual and physical disabilities

risk factor for adverse pregnancy outcomes: smoking

Preterm birth and LBW

greatest risk from environmental factors

-Embryo is at greatest risk from environmental factors between day 17 and day 56 after conception

-The nurse's role as advocate and educator is paramount

Importance of Adequate Glycemic Control

Should be addressed preconception and interconception

Incidence of diabetes in pregnancy has been increasing related to increased obesity

A1C

-Measures average blood glucose level over past 3 months

-Should be lower than 6.5% prenatally

-Should be lower than 6-7% in pregnancy

-Elevated levels are associated with congenital anomalies, pre-eclampsia, macrosomia

**if she enters pregnancy with DM already, otherwise A1C not used a lot bc its measured over months

recommendations for adequate glycemic control

Self monitoring of fasting and post prandial blood glucose levels

ADA targets for women with Type 1 or Type 2 Diabetes

-Fasting: Below 95 mg/dL

-1 hour postprandial: Below 140 mg/dL

-2 hour postprandial: Below 120 mg/dL

Treatment Recommendations for Gestational Diabetes

-Gestational Diabetes: Manifests for first time during pregnancy **while pregnant, not bc she is pregnant

-First treatment: Diet control

-Second treatment: Insulin (does not cross the placenta)

-Third treatment: Oral hypoglycemic

Components Specific to a Prenatal Visit

Due date determination

Abdominal/uterine assessment

Fetal development

Pelvic adequacy

Screening tests

Scheduling future prenatal visits

gravid

"The state of being pregnant"

gravida

-Total number of times a woman has been pregnant, regardless of the outcome

-Inclusive of multiple infants born

para

"Number of times a woman has given birth to a fetus of at least 20 weeks' gestation (viable or not) with multiple births counting as one birth event."

due date determination at first prenatal visit

-Naegele's Rule:

-First day of LMP - 3 months + 7 days = EDD/EDB

-Accurate determination of gestational age is vitally important.

prematurity

"Globally, prematurity is the leading cause of mortality in children less than 5 years of age."

GTPAL

-TPAL=para

-Method utilized for calculating a woman's obstetric history

G

Gravity: Total number of pregnancies. Include the current pregnancy (Think "Gravid/Gravida")

T

Term: Term births. Delivered between 38- and 42-weeks gestation

P

Preterm: Preterm births. Pregnancy ending > 20 weeks but prior to completion of the 37th week of gestation

A

Abortion: Pregnancies ending prior to 20 weeks or viability (spontaneous or elective/therapeutic)

L

Living: Currently living children to whom the woman has given birth

The First Prenatal Visit: Abdominal Assessment

Striae

Linea nigra

Muscle tone (effects of progesterone)

The First Prenatal Visit: Uterine Assessment (fundal height)

-Top of pubic bone to top of uterus (fundus)

-Patient lies on her back with knees slightly flexed

-Correlates well with weeks of gestation between 22 and 36 weeks (+/- 2 cm)

accuracy with fundal height

-More accurate: Same examiner each time (not realistic)

-Less accurate: later in pregnancy

-Inaccurate: Maternal obesity, Uterine fibroids,

Hydramnios

weeks and where the fundal height is

12 weeks: At the symphysis pubis

16 weeks: Midway between symphysis and umbilicus

20 weeks: At the umbilicus

36 weeks: Just below the xiphoid

Estimating gestational age during pregnancy

-Most accurate: Ultrasound

-Other methods: Maternal recall of LMP (use of Naegele's Rule)

-Fundal height measurement: After 20 weeks' gestation

Estimating gestational age after delivery

Dubowitz scoring (term/pre-term) **look at lanugo and creases on feet

The First Prenatal Visit: Fetal Development assessed via

-Quickening (between 16 and 22 weeks gestation)

-FHR (Doppler, 10-12 weeks)

-U/S (gestational sac at 4-5 weeks

fetal heartbeat at 6-7 weeks)

quickening

Mom's first experience of feeling fetal movement (subjective)

The First Prenatal Visit: Pelvic Adequacy/Pelvimetry

-Not a determinate for vaginal birth

-diagonal conjugate

-true (obstetric) conjugate

-ischial tuberosity diameter

diagonal conjugate

-Most useful in estimating pelvic size

-Fetal head passes through here first

-Should be 11.5 cm or greater

-false pelvis directs the baby into the true pelvis

-Distance between anterior surface of sacral prominence and anterior surface of symphysis pubis.

true (obstetric) conjugate

-Estimated measurement (cannot be directly measured)

-Subtract 1-2 cm from diagonal conjugate

-Should be at least 10 cm for a vaginal delivery

-Smallest front to back diameter through which fetal head must pass

-Distance from anterior surface of sacral prominence to posterior surface of symphysis pubis

ischial tuberosity diameter

-Measured externally

-Adequate = 10.5 cm or greater (for passage of fetal head)

The First Prenatal Visit: Screening Tests

-Pap (if indicated; cervical cells)

-CBC: Hgb. (12-14 g) and Hct. (42% +/- 5%)

-HIV screening

-Rubella titer

-ABO and Rh typing

-Urine culture (also done at each visit; to make sure no UTI)

-Hep B screen

-STI testing (syphilis, chlamydia, gonorrhea):

Repeat at future visits if necessary **beginning of pregnancy and before delivery

The First Prenatal Visit: Scheduling Future Prenatal Visits

-First 28 weeks: every 4 weeks

-29 -36 weeks: every 2 weeks

-37 weeks - delivery: every week

Future Prenatal Visits: Assessments

-Weight and B/P

-Urine sample: Check for protein, glucose, ketones and nitrites

-Fundal height measurement: Assess fetal growth

-Quickening/fetal movement: Assess fetal well-being

-FHR: Normal = 110 - 160 beats per minute (bpm)

Future Prenatal Visits: Determining Fetal Movement (quickening)

-Mother's first perception of fetal movement (subjective)

-Multiparous earlier than nulliparous

Monitoring fetal activity at home: teach mom

-how (varied methods)

-length of time it takes to record 10 fetal movements (if > 2 hours... call HCP)

-purpose

-same time each day

-report any decrease in fetal activity/movement **after you feel it, it should be felt everyday

Screening for Gestational Diabetes

-24-28 weeks gestation

-1 hour OGTT (Oral Glucose Tolerance Test)

-Desired value = < 140 mg/dL

-If > 140 mg/dL a 3-hour diagnostic OGTT is done

**not before 20 weeks, doesn't show up in the 1st trimester

Edema (periorbital, hands, face, pretibial)

-29 - 36 weeks gestation

-gestational HTN, in 3rd trimester

-dependent, ankles feet

RhoGAM administration

-28 weeks gestation

-Rh-negative moms

-not given early in pregnancy

GBS

-37 - 40 weeks gestation

-risk factor at delivery so must be tested early

Chlamydia and Gonorrhea

-37 - 40 weeks gestation

-test at beginning of pregnancy and close to delivery

fetal position

-37 - 40 weeks gestation ... Leopolds

-closest to the Due date so baby should be settled in

Nursing Management for the Common Discomforts of Pregnancy: important points

-Identify the discomfort

-When in pregnancy (trimester) does it typically occur .. begin and end

-Recommendations for relief of symptoms (Health Promotion)

-When would we be concerned?

first trimester common discomfort

•Nausea and Vomiting of Pregnancy (NVP)

•Urinary frequency

•Fatigue: progesterone

•Breast tenderness: hormones, tends to end by the first trimester

•Constipation: decreased peristalsis from progesterone

•Nasal stuffiness, bleeding gums, and epistaxis: from estrogen

•Ptyalism: excessive saliva

•Food cravings

•Leukorrhea: increased vaginal discharge **DM at risk for yeast infection

Discomforts can begin in or be associated with one trimester though may continue through or re- occur in successive trimesters

:)

second trimester eases

-Ending of NVP

-Ending of breast tenderness

-Urinary frequency eases

-Fatigue eases

-Other first trimester discomforts may continue

second trimester discomforts

-Backache

-Leg cramps: charlie horses, dorsiflex to relieve

-Varicosities: support hose, but not knee-high

-Hemorrhoids: internal/external, use witch hazel, tucks, preparation H

-Flatulence and bloating: progesterone and diet, teach to walk every day

third trimester occurrences

-Urinary frequency returns

-Fatigue increases

-Other first and second trimester discomforts may continue

third trimester new onset discomforts

-Shortness of breath and Dyspnea: baby pressing up on diaphragm

-Pyrosis: progesterone and baby pushing up

-Dependent edema

-Braxton Hicks (for some, these begin in the 2nd trimester): from stretching of the uterus, no regular interval, recommend fluids/sit/stand/warm shower...whereas real labor this won't help bc its a hormone issue (low prog, high oxytocin)

Nausea and Vomiting of Pregnancy (NVP) causes

Multifactorial (hormones, metabolism, emotions, low B-6, others)

Nausea and Vomiting of Pregnancy (NVP) begins

5th week after LMP (2nd - 3rd week of pregnancy)

Nausea and Vomiting of Pregnancy (NVP) peaks

8-12 weeks

Nausea and Vomiting of Pregnancy (NVP) ends

16-18 weeks

Nausea and Vomiting of Pregnancy (NVP) treatment

-Frequent, small meals (snacks, carbs)

-B-6 (foods, vits.)

-Non-med.: Ginger, acupressure, wristbands

-Meds: (HCP consult)

Diclegis: (doxylamine pyridoxine .. A combination antihistamine and B-6)

Benadryl

Dramamine

Urinary frequency or incontinence cause

pressure on bladder

Urinary frequency or incontinence trimesters experienced

1st trimester (uterus ... 2 oz to 2 lbs.)

3rd trimester (uterine contents)

Urinary frequency or incontinence teach

Reduce fluids prior to bedtime

S/S of infection

fatigue cause

trimester dependent

-1st trimester (hormones, metabolic demands, psychosocial factors)

-**** 2nd trimester = highest energy (usually)

-3rd trimester (physical changes and discomforts)

teach about fatigue

Rest often, use pillows

Left side (preferred)

breast tenderness (cause/trimester/teach)

-Hormones (estrogen/progesterone)

-Trimester: First

-Teach: Supportive bra (even when sleeping)

ptyalism (what/cause/trimester/teach)

-What is it: Excessive secretion of saliva

-Cause: Unknown

-Trimester: 1st (begins), 2nd and 3rd (continues)

-Treat/teach: hard candy, gum, no real treatment

food cravings (cause/trimester/teach)

-Cause: Unknown

-Trimester: 1st (begins), 2nd and 3rd (continues)

-Teach: Moderation

constipation causes

Hormones (progesterone)**slows things down

Increased uterine size (pressure)

Increased water reabsorption

Calcium and Iron in PNV **iron is constipating

constipation trimesters

First (begins)

Second and third (continues)

teaching about constipation

-Diet (fiber and fluids)

-Physical activity: walk everyday

-Maintain normal bowel patterns

-Adequate fluids/water, warm fluids to stimulate the bowel

-Reduce refined carbs and cheese: in moderation

-Consider a bulk-forming laxative (Metamucil) per HCP: stretches bowel for BM

Nasal stuffiness, Bleeding gums and Epistaxis (estrogen) cause and trimesters

-edema of nasal mucosa from estrogen

-1st (begins), 2nd and 3rd (continues)

Nasal stuffiness, Bleeding gums and Epistaxis (estrogen) teaching points

Stay hydrated

Cool mist humidifier

No nasal decongestants/sprays

nosebleed teach

Tilt head slightly forward

Pinch nose (10-15 minutes)

Apply ice to bridge of nose (vasoconstriction)

bleeding gums teach

Soft toothbrush

Warm saline mouthwash

Good dental care

leukorrhea (what/cause)

What is it: Increased vaginal discharge

Cause: Estrogen (hyperplasia of the mucosa)

leukorrhea trimester

1st (begins), 2nd and 3rd (continues)

teach with leukorrhea

S/S of yeast infection (increased risk)

Cotton undergarments

Good hygiene

**soap and water only, no bubble bath sprays or deodorants

backache (cause/trimester)

Cause: Uterine size, spinal curvature, relaxed pelvic structures

Trimester: 2nd (begins) 3rd (continues)

backache teach

Heat, ice, massage

Posture, body mechanics, support shoes

Exercises .... Pelvic tilt

Tylenol (per HCP) **last resort

leg cramps (cause/trimester)

Cause: increased strain, muscle fatigue

Trimester: 2nd (begins) 3rd (continues)

leg cramps teach

Adequate Ca++ and PO4-, fluids

Dorsiflex foot

Elevate

Warmth, moisture on muscles

Support hose, low shoes

Varicosities of Vulva and Legs (cause/trimester/teach)

-Cause: Slowed venous return (gravid uterus)

-Trimester: 2nd (begins) 3rd (continues)

-Teach: Elevate legs, no crossing legs

Support hose (no knee-highs)

hemorrhoids (what/cause)

-What is it: Varicosities of the rectum (may be internal or external)

-Cause: Pressure (gravid uterus)

hemorrhoids teach

-How to prevent constipation

-Avoid prolonged sitting/standing

hemorrhoids treat

Preparation H

Anusol

Witch hazel or cool compresses

flatulence and bloating (cause/trimester)

-Cause: Decreased GI motility (progesterone, pressure from gravid uterus)

-Trimester: 2nd (begins) 3rd (continues)

flatulence and bloating teach

-Avoid gas-producing foods (beans, cabbage, onions) and foods with high white sugar content

-Reduce intake of carbonation, cheese

air swallowing (eat slowly)

-Action daily exercise, adequate fluids,

mints

Shortness of Breath and Dyspnea (cause/trimester)

Cause: hemodynamic changes, gravid uterus

Trimester: 3rd (usually)

SOB and dyspnea teach

Position changes

HOB up

Left side

Stretch (arms up, deep breaths)

Small meals

Relieved some after lightening (baby "drops")

Heartburn (Gastroesophageal reflux, Pyrosis) and Indigestion (causes/trimester)

-Causes: Progesterone (relaxes cardiac sphincter)

-Gravid uterus (displaces stomach, slows emptying)

-Trimester: 3rd (usually... could occur earlier)

Heartburn (Gastroesophageal reflux, Pyrosis) and Indigestion teach

-Avoid caffeine, alcohol, chocolate, citrus, spearmint/peppermint, spicy/greasy food

eating before bed

-Limit gas-producing or fatty foods

air swallowing (fast eating, gum chewing)

-Do eat slowly, small meals, upright after eating

dependent edema (where/cause)

-Where: legs/feet, face, periorbital area

-Cause: Slowed venous return (gravid uterus)

Increased fluid volume in pregnancy (6-8 liters)

Increased capillary permeability

-3rd trimester

dependent edema tx

Elevate feet/legs above heart

Support stockings (no knee highs)

Walk

Left side

Fluids (water)

Monitor sodium, sugar, fatty foods