Nursing Management During Pregnancy

What are common laboratory tests performed on pregnant patients?

-CBC/blood typing

-Rubella titer, Hepatitis B

-STI screening --> HIV

-Cervical smears --> pap

How would you obtain fetal movement counts to do an assessment of fetal weelbeing?

-10 movement felt within 2 hours --> contact provider if decreased movement noted

-only performed after 20 weeks minimum --> once fetal movements are felt routinely

-relaxed environment, side-lying, same time daily

Why are fetal ultrasounds performed?

monitor fetal growth, implantation/placenta, twins, organs

When do you use a trans-vagina ultrasound?

-empty bladder

-early --> first trimester

When do you use an abdominal ultrasound?

-full bladder

-used by beginning of second semester for 16-20 week fetal anatomy scan

What is Alpha-fetoprotein analysis?

-sample of mother's blood to evaluate levels of protein produced by fetal liver & yolk sac --> crosses placenta into maternal blood

What do increased levels of Alpha-fetoprotein indicate?

Neural tube defects, Turner syndrome, multiple gestation

What do decreased levels of Alpha-fetoprotein indicate?

Down syndrome or Trisomy 18

When is Alpha-fetoprotein analysis usually performed?

15 to 18 weeks

What are tripe & quad screening tests?

used to identify risk for Down syndrome, neural tube defects, & other chromosomal disorders

-Triple: alpha-fetoprotein, estriol, beta-hCG*

-Quad: * & inhibin A

When are triple & quad screening tests performed?

15 to 18 weeks

Define aneuploidy

occurrence of one or more missing or extra chromosomes

What is Nuchal Translucency Screening?

intravaginal ultrasound to measure for subcutaneous fluid accumulation behind the fetal neck

-associated with Trisomy's 13, 18, 21, Turner syndrome, cardiac defects

When is nuchal translucency screening performed?

11 to 14 weeks

When do you perform an amniocentesis?

between 15-20 weeks gestation --> can be done all trimesters

-first & second semester for genetic testing

What are the adverse effects of amniocentesis & post-procedural management?

-Adverse effects: spontaneous miscarriage in first trimester

-Post-procedural Management: RhoGam for Rh- moms, observe puncture site for bleeding, leaking fluid, return if vaginal bleeding or decreased fetal movement, VS q 15 min x1 hr

How do you perform an amniocentesis?

transabdominal puncture amniotic sac --> sterile procedure

-empty bladder

-EFM 20 prior procedure

Why is an amniocentesis performed in the third trimester?

assess fetal lung maturity after 35 weeks

What is Chorionic Villus Sampling?

invasive procedure w/ an 18-gauge needle stick through abdomen or passage of a suction catheter through cervix --> both under ultrasounds guidance

-done to obtain a sample of the chorionic villi from the placenta to assess for chromosomal disorders (NOT neural tube defects)

When is Chorionic Villus Sampling performed?

10 to 13 weeks, results available in less than 1 week

-can be performed earlier & safer than amniocentesis

Describe post-procedure care for Chorionic Villus Sampling

-EFM

-Rhogam for Rh- moms

-no strenuous activity for 48 hours

-return to L&D if fever, cramping, vaginal bleeding

What is a Non-stress Test?

provides an indirect measurement of uteroplacental function -reactive: normal increase in HR

-nonreactive: absence FHR accelerations

When do are NSTs performed?

after 28 weeks gestation --> fetal CNS is well enough developed

How do you perform a NST?

through electric fetal monitoring (EFM)

-eat prior assessment

-left lateral recumbant

-takes 20-30 minutes

-mom hits button every time she feels fetal movement (event marker) --> should see corresponding spike in FHR

What is a CST?

contraction stress test --> not commonly used anymore

How do you determine if something is an acceleration a NST?

an increase of 15 bpm above baseline lasting > 15 seconds (< 2 minutes)

What is a biophysical profile?

scoring system to evaluate fetal well-being --> high risk pregnancies, non-reactive NST

What is a normal score on a BPP?

8 to 10

< 6 = suspicious

What are the five parameters of a BPP?

Five parameters:

1) NST results

2) Fetal tone

3) Fetal movement

4) Fetal breathing

5) amniotic fluid index

What is a modified BPP?

only looks at the NST results & amn8iotic fluid index

What is the purpose of preconception counseling?

to ensure mom & dad health prior to conception --> identify & modify health risks

What is the purpose of inter-conception counseling

time between pregnancies where mother can improve health --> avoids poor outcomes/adverse effects

Do you receive counseling if you are not intending to become pregnant?

preconception care includes contraception education & monitoring overall health that could be affected by pregnancy

What occurs at the first prenatal visit?

-screen risks (PTL) & address coming life changes

-screen for diabetes

-comprehensive health history

-physical examination --> pelvic exam

-labs

First visit: comprehensive health history

-reason seeking care --> last menstrual cycle, s/s, hCG test

-medical, surgical, personal history of both parents & family

-reproductive history (LMP, OBGYN hx), EDD

First visit: physical examination

clean catch urine specimen, VS, weight, head-to-toe assessment, pelvic exam

First visit: pelvic examination

includes internal & external genitalia w/ pelvic size/shape/measurements

-4 shapes: gynecoid, android, anthropoid, platypelloid

-pelvic measurements are unnecessary w/ prior vaginal births

What are the 3 pelvic measurements assessed?

Internal:

-diagonal conjugate (12.5cm)

-true conjugate (indirectly measured)

External:

-ischial tuberosity diameter (10.5 cm)

What laboratory tests would be obtained at the first prenatal visit?

-UA --> albumin, glucose, Ketones, bacteria

-CBC, blood typing, Rh factor

-glucose testing

-cervical smears --> STIs

-rubella/Hep B/ HIV screenings

Describe the routine of care for prenatal visits

- q 4 weeks until 28 weeks gestation

- q 2 weeks from 29-36 weeks gestation

-weekly from 37 weeks gestation until birth

When do you perform a gestational diabetes screening?

between 24-28 weeks

- >140 mg/dL --> further testing is required

Describe assessments completed at follow up prenatal visits

-weight, BP, FHR

-UA

-fundal height --> monitor fetal growth

-assess for quickening/fetal movements

What is the normal fetal HR range?

110-160 bpm

What does edema indicate in physical assessment in prenatal visits?

-special focus in last trimester

-LE edema is common --> periorbital, pretibial, hand edema are abnormal & indicate gestational HTN

What do you do for Rh negative moms?

-antibody titer evaluation

-RhoGAM is used to prevent antibodies from transmitting to Rh-positive fetal cells

What are the s/s preterm labor?

contractions, backache, pelvic/thigh pressure, cramps, bleeding, increased discharge, dilation/effacement, fetal membranes rupture

Describe danger signs to assess for in the first trimester of pregnancy

spotting (miscarriage), abdominal pain w/ persistent vomiting, dizziness/fever, painful urination (infection)

Describe danger signs to assess for in the second trimester of pregnancy

no fetal movement >12 hours, calf pain (DVT), regular contractions/vaginal leakage (PTL)

Describe danger signs to assess for in the third trimester of pregnancy

decreased fetal movements >24 hours, weight gain d/t abnormal edema, upper abdominal pain

Describe preterm labor contractions

q 10 minutes w/ labor s/s

Describe Braxton Hicks contractions

-not true labor pains

-go away when walking, resting, sleeping

felt in abdomen rather than back like true labor