Nursing management during pregnancy

Diagnosis of pregnancy

• amenorrhea, nausea, fatigue: Most common reasons for pregnancy test

• Positive pregnancy test:

  • HCG levels increase

  • most use urine from first void in morning

  • detectable 3-10 days post conception

Schedule for pregnancy dr. visits

• initial: 8-10 weeks

• monthly appt until 28 weeks

• every 2 weeks from 28-36 weeks

• Weekly from 37 weeks until delivery

Initial prenatal visits includes

• obstetric history

• menstrual history, LMP

• GYN history and contraception

• Med history

• Surg history

• Meds

• Family history/genetics

• Psychosocial history

• cultural aspects

• partners health and habits

• immunization status

Initial prenatal visit physical exam

• vital signs

• maternal height and weight

• urinalysis

• general physical exam

• pelvic exam

• assessment of gestational age: uterine size compared with LMP, ultrasound

How many weeks to hear fetal HR on doppler

10-12 weeks

routine lab studies

• blood type, Rh, antibodies screen, hemoglobin, hematocrit, platelet count

  Screens for:

• Hep B antigen

• syphilis or veneral disease tests

• HIV

• rubella immunity

• Chlamydia or gonorrhea

• cervical cancer screening

• urinalysis and urine culture

Initial visit education

• expected course of pregnancy

• risk factors

• referral to genetic counselor

• Dos and donts

• Prenatal vitamins

• danger signs

Example of high risk pregnancies

• under 16 y/o or over 35 y/o

• poverty/financial status

• pre-pregnancy weight: underweight or obese

• substance use, alcohol, tobacco, drug use

• pre-existing medical conditions

• multiple gestation (more than one fetus)

• Rh sensitization

• placental abnormalities

• previous preterm birth

• Pre-eclampsia

• gestational diabetes

• previous fetal demise

fundal height

• 12 weeks: fundus initially palpable

• 16 weeks: halfway between symphysis and umbilicus

• 20 weeks: fundus at umbilicus

screenings

• 24-28 wks: gestational diabetes screening

• 27-36 weeks: tdap vaccine administered if needed

• 28 weeks: hemoglobin and hematocrit

• 36 weeks: group B strep culture swab

screening tests definition

• non-invasive

• low risk

• inexpensive

• offered to a broad population

• use to identify the need for a diagnostic test

diagnostic test definition

tests to identify specific problems with high degree of accuracy

• expensive

• involves some risks

• requires special equipment or personnel

• still has limitations

Ultrasound

high frequency sound waves produce images

Purpose of ultrasound

1. confirm pregnancy and viability

• embryo can be seen at 5-6 weeks gestation

• heartbeat visualized at 6-7 weeks

2. Determine gestational age- by measuring the crown rump length via ultrasound (MOST RELIABLE)

3. Identify the presence of multiple fetus

4. Locate the position and evaluate the placenta

5. guide needle placement for diagnostic procedures such as amniocentesis

6. evaluate the fetal anatomy: routine at 18-20 weeks

7. assess fetal growth

Alphafetoprotein AFP

level determined by a maternal serum blood draw

protein that is synthesized in fetus then excreted into the amniotic fluid and crosses the placenta and enters maternal circulation

this screening is offered to women between 16-18 weeks

AFP screening tests for two things

1. low levels indicate possible chromosomal abnormalities

2. high levels indicate possible neural tube or fetal body defects

• abnormal results require further testing

• inaccurate gestational age can skew results: needs to be between 16-18 wks to be accurate

If AFP screening comes back normal

• next is triple marker screening which tests for MSAFP, hCH, and estridol

• next is thats abnormal: Quad marker screening: looks at inhibin A and the same triple marker components

Diagnostic tests for chromosomal abnormalities is only offered to:

• maternal age 35 or older

• pervious pregnancy or family history of chromosomal abnormalities

• inherited genetic disorders

• gender determination for sex-linked disorders

• abnormal MSAFP or multiple marker screenings

Amniocentesis indications

• chromosomal testing

• determine fetal sex (wont do just for this)

• Rh sensitized mothers to obtain fetal blood type and bilirubin levels

• to check for fetal lung maturity in early 3rd trimester for mothers with history of pre-term deliveries (is lungs aren’t mature- give meds)

• best preformed at 15 weeks minimum

when is amniocentesis best preformed

at least 15 weeks gestation, not enough amniotic fluid before this

Chorionic villus sampling

• aspirates villi for chromosomal analysis

• They are finger like projections of placental tissue in uterus

• done at 10-12 weeks gestation

Risks of chorionic villus sampling

pregnancy loss

Late pregnancy assessments

in 3rd trimester

• determination of fetal presentation and engagement of presenting parts

• testing for fetal wellbeing

• tests for readiness for labor and delivery

late pregnancy assessments

• leopolds maneuver

• pelvic exam

• ultrasound

• kick counts

• non-stress test

• contraction stress test

• biophysical profile

• Amniotic fluid index

• bishops score

Assessments to determine fetal position

• leopolds maneuvers: palpating position

• Pelvic exam: especially during labor (digital)

• ultrasound: confirms physical exam findings

Third trimester pelvic digital exam determines

• characteristics of cervix

• dilation status

• effacement: how thin cervix is

• consistency: becomes softer as labor progresses

• position of cervix: posterior or anterior

• presenting part of fetus: vertex or breech

• fetal station: location of fetus in relation to mothers pelvis

• engagement: how the fetus settled into pelvis

Tests for fetal well being

• concern is for adequate oxygenation and potential for hypoxia during labor

• kick counts

• non-stress test

• contraction stress test

• biophysical profile BPP

• amniotic fluid index

When to start fetal kick count

• after 28 weeks

• twice daily or more

• at the same time each day

when does viability of pregnancy start

22 or 23 weeks

Non-stress test

• fine line of assessment for fetal wellbeing

• non-invasive

• painless

• uses external fetal monitor

• observes fetal HR in response to fetal movement

• also sees uterine activity/contractions

Criteria for NST

• must have 2 FHR accelerations within a 20 minute period at least 15 beats above baseline for at least 15 seconds

Contraction stress test

involves fetal monitoring while stimulating contractions

fetus with adequate oxygenation reserves can tolerate the stress of contractions and can tolerate labor

fetus without can not tolerate

meds given: pitocin

5 components to BPP (biophysical profile)

1. NST

2. fetal breathing movements

3. gross fetal movements

4. fetal tone

5. amount of amniotic fluid

score of 0-2 for each component

A score of 8-10 is reassuring

lower scores require follow up

Amniotic fluid index

measure of chronic fetal hypoxia

• hypoxic fetus shunts blood to vital organs at the expense of organs not critical during fetal life

• lungs and kidneys produce amniotic fluid: during chronic hypoxia their function is compromised leading to low amniotic fluid

Oligohydramnios is an indicator of

chronic hypoxia

Bishop score

• evaluates cervix and fetal station to predict readiness for labor

• Higher score: better probability of successful induction of labor

• Perimeters evaluated

  • Cervical dilation

  • cervical effacement

  • fetal station

  • cervical consistency

  • cervical position

score of 5 in multiparas and score of 7 in primiparas predict a successful labor induction

What to report to provider

• vaginal bleeding

• abdominal pain

• fever about 100.4

• persistent vomiting

• severe headache

• swelling of hands and face

• epigastric pain or heart burn

• visual disturbance

• dysuria

• sudden gush of fluid from vagina

• contractions

Pre-eclampsia symptoms

• headache

• blurred vision

• seeing spots

• swelling of hands and face

• heart burn