Nursing Management during Pregnancy

Severe maternal morbidity

serious/life-threatening pregnancy-related complications that can have short- and long-term impacts on the health of the birthing person and their baby

• around 50,000 people experience each year

• Birthing people < age 20 or >35 have higher rates

Health disparities in obstetrics

• Systemic/structural roots

Complex intersection of social, economic, & political contexts leads to health inequities

• Birthing people impacted:

Black, Indian/Alaska Native, Hispanic, LGBTQIA+, Low Income, Rural

Implicit bias among OB providers

• Unequal treatment recommendations

• Disparities in pain management

• Poor patient-provider relationships; mistrust; not believing patients/not taking their concerns seriously

• Lower quality of care

• Increased morbidity & mortality

Preconception & Interconception care

Start folic acid/prenatal vitamins early!

• Illicit drugs, alcohol, smoking

• Lab work; Immunizations

• Genetic counseling & testing

• Nutritional status

• Lifestyle practices

• Psychosocial issues

• Support system

Initial “pregnancy confirmation” visit

• Urine pregnancy test (probable pregnancy sign); Assess for other probable or presumptive signs

• Nagele’s rule to determine Estimated Date of Confinement (EDC) or Estimated Date of Delivery (EDD)

• Explore patient’s feelings surrounding pregnancy; offer non-directive options counseling

• If pregnancy is desired, obtain ultrasound; most accurate means of dating

Nagele’s rule

• 1st day of last menstrual period (LMP)

• Subtract 3 months

• Add 7 days

• Add 1 year

First prenatal visit: Complete health history & Physical exam

Chief report/History of Present Illness (HPI)

Past history: demographic info, partner info, medical, surgical, psychiatric, social, medications/possible

teratogens, allergies, immunizations

Obstetrical/Gynecological history

• Menstrual cycles – last menstrual period, cycle length/regularity, contraception use

• Gravidity and parity: number of previous pregnancies & outcomes; pregnancy details (type of birth, birthweights, high risk issues such as gestational diabetes, preeclampsia, etc.)

• Last pap smear/history of abnormal paps , known gyn issues, h/o STIs and tx, discharge/lesions

Family history & genetic history (helpful if partner present for this visit)

Review of systems

Health patterns & screenings (mental health, intimate partner violence, substance use)

First prenatal visit: Head and Neck exam

Inspect mouth for dental/gum disease; nasal erythema; thyroid enlargement

First prenatal visit: Chest exam

Split S1/S2; S3 (maybe); Anticipate slightly increased HR after 1st TM; increased resp rate in 3rd TM; inspect breasts for tenderness or masses

First prenatal visit: Abdomen exam

Soft? Non-tender? Fundal height

First prenatal visit: Extremities exam

Dependent edema, varicosities

Skin/MSK

First prenatal visit: Pelvic exam

• External & internal genitalia exam (lesions, s/sx infection); speculum for pap smear/visualize cervix

• Bimanual exam (assess size & shape of uterus/ovaries)

• Assessment of pelvic shape

Gravid

State of being pregnant

Primigravida aka “prime”

First pregnancy

Para/Parity

# of births of a fetus of at least 20 gestational weeks (alive or not), counting multiple births as one birth event

Primipara aka “primip”

One birth after a pregnancy of at least 20 weeks’ gestation

Gravidity & Parity (G P)

basic 2-digit system that only gives information about the # of pregnancies & births, i.e., G5 P3; G1 P0

The 5-digit GTPAL system

provides more comprehensive data about the para part of the obstetric history

• para is further broken down to give more information about the birth history

TPAL

• “Term” = 37 wks to 42 wks

• “Preterm”- 20 wks - 36.6 wks

• “Abortion”- early losses prior to 20 wks

• “Living children” - currently living offspring

First Trimester Laboratory Tests

• CBC

• Blood type (A, B, AB, O) & antibody/antigen

• Rh Factor - presence (+) or absence (-) of Rh protein; if negative, will need Rhogam at 28 wks & up to 72 hrs postpartum

• HIV, RPR, Hep B, Hep C; Hep B antibody

• G/C/T; Pap smear if due

• MMR & Varicella titers

• HbA1c if risk factors

• Urine Culture; urine analysis at every visit

• Optional: Cell-free DNA/Non-Invasive Prenatal Testing (NIPT)

Second Trimester Laboratory Tests

• Optional: Triple/Quad screen/Alpha-fetoprotein (AFP) 15-20 wks (neural tube defects & chromosomal disorders)

• Glucose tolerance test between 24-28 weeks

Third Trimester Laboratory Tests

• CBC

• Recheck antibodies for Rh negative

• HIV, RPR

• G/C/T if risk factors

• Group Beta Strep (GBS) at 36 weeks

Common Tests during Pregnancy

thyroid panel, CMP for electrolytes, kidney function; PT/PTT for clotting factors; cystic fibrosis, spinal muscular atrophy, & sickle cell screeningsImmunizations during pregnancy

Recommended Immunizations during pregnancy

• Influenza (inactivated) injection

• COVID-19

• RSV (Respiratory syncytial virus)

• Tetanus/diphtheria (TdaP)

• Hepatitis B

Contradindicated Immunizations during pregnancy

• Live, attenuated influenza (nasal spray)

• Measles/Mumps/*Rubella*

• Varicella

• BCG (tuberculosis)

• Typhoid

Recommended visit schedule

• Every 4 weeks up to 28 weeks (1st TM - beginning of 3rd TM)

• Every 2 weeks from 29 to 36 weeks

• Every week from 37 weeks to birth

At each subsequent prenatal visit, the following assessments are completed

• Weight, blood pressure, urine; continually compared with baseline/trending values

• Fundal height measurement to assess fetal growth (usually after 16 weeks)

• Assessment of fetal heart rate

• Assessment for quickening/fetal movement

• Assessment for vaginal bleeding, contractions, leakage of fluid

Assessment of fetal growth

• Fundal height measurement (assesses fetal growth)

• Paper tape measure (measure in cm)

Patient lies supine (slight left tilt, empty bladder)

Start at top of symphysis pubis, end at fundus

Most reliable between18-32 weeks

• 12 weeks – ascent into pelvis

• 20 weeks – level of umbilicus

• 36 weeks – xiphoid process/breastbone

• 38-40 weeks – lightening = drops lower

• ** Should be within 2 cm of gestational age; ultrasound needed if ≥ 4cm difference

Fetal Movement Measurement

• 1st perception of movement = “quickening”

• “Kick counts” - No research to support exact # of reassuring movements.

• General guideline: 10 movements in 2 hours (start at about 28 weeks)

• Quiet environment, focused, same time each day

• No movement = eat a snack, drink something, talk to baby, stimulate

• Taking longer than 2 hours to elicit 10 movements could indicate poor fetal status

Fetal Heart Rate Measurement

• 1st assessed 10-12 weeks via doppler (6 wks on US)

• Earlier gestation = lower in abdomen/pelvis; Determine fetal lie

• Listen for full minute (normal = 110-160), **Need to differentiate between maternal & fetal HR

Problems requiring Urgent Assessment

• Vaginal bleeding

• Leakage of fluid from the vagina

• Dysuria; abnormal vaginal discharge

• Reduced fetal activity (after approx. 26 – 28 weeks)

• Severe nausea/vomiting – (preclampsia) hyperemesis gravidarum

• Headache not relieved by Tylenol, ice packs, dark room etc.

• New onset visual changes like blurriness/diplopia/floaters (preclampsia)

• Menstrual-like cramps unrelieved with rest, hydration, heat

• New onset lower back/thigh pain; pelvic pressure

• Early pregnancy: intense lower abdominal pain (often one-sided)

Fetal well being Screening

• Ultrasound (4-8 wks transvaginal; 16-20 wks abdominal; possible additional US’s)

• Optional: Nuchal translucency ultrasound 11-14 wks (chromosomal disorders)

• Nonstress test (NST) (generally 28+ wks)

Biophysical profile (BPP)

• Contraction Stress Test

• Doppler flow studies (28+ wks)

Invasive diagnostic genetic tests

• Chorionic villus sampling (CVS)10-12 wks

• Amniocentesis 15-20 wks

Nonstress Test (NST)

• Evaluates fetal well-being through fetal heart rate variability & reactivity

• Performed at/after 28 weeks gestation in presence of fetal/maternal risk factors

• Patient placed on electronic fetal monitor (EFM), button pressed whenever fetal movement is felt.

• Testing takes 20-40 minutes

Nonstress Test (NST) Results

• Reactive NST = normal FHR baseline with moderate variability and ≥ 2 accelerations of 15BPM for 15 seconds over a 20-minute period

• Non-reactive NST = poor variability, abnormal baseline, failure to achieve accelerations → Biophysical Profile (BPP)

Biophysical Profile (BPP)

An ultrasound that evaluates fetal well-being by assessing five markers, each worth 2 points if present or 0 points if absent:

1. Fetal movement

2. Fetal tone

3. Fetal breathing

4. Amniotic fluid volume

5. NST reactivity

• Total score is out of 10 points

8-10 = reassuring

6 = equivocal/suspicious

4 or less = non-reassuring

First Trimester Discomforts

• Urinary frequency

• Fatigue

• Nausea and vomiting

• Breast tenderness

• Constipation

• Nasal stuffiness, bleeding gums, epistaxis

• Cravings

• Leukorrhea

Second Trimester Discomforts

• Backache

• Varicosities of the vulva and leg

• Hemorrhoids

• Flatulence with bloating

• Braxton Hicks

Third Trimester Discomforts

• Return of first trimester discomforts (ex. fatigue, urinary frequency, leukorrhea)

• Shortness of breath

• Heartburn and indigestion

• Dependent edema

• Braxton Hicks

Nursing Management of discomforts

• Urinary frequency: Kegels, regular bladder emptying, avoid caffeine

• Fatigue: full night sleep, good nutrition

• Nausea/vomiting: small frequent meals, avoid spicy/greasy/hot foods, bedside crackers

• Leukorrhea – pantiliner, cotton underwear

• Backache – yoga, stretching

• Varicosities/lower extremity edema – elevate feet, walk daily, support hose

• Hemorrhoids & constipation – increase water, fiber, movement, warm sitz bath & cool witch hazel pads

• Heartburn/indigestion – avoid fried, citrus/acidic foods, soda/chocolate, avoid late night eating, elevate HOB

Nursing management: Promote self care

• Personal hygiene/perineal care

• Avoidance of saunas/hot tubs

• Dental care

• Breast care

• Nutrition & hydration

• Exercise (with precautions)

• Sleep and rest

• Sexual activity

• Employment

• Travel

• Immunizations & medications

Birthing Education

• Perinatal education

• Childbirth education (Lamaze, Bradley method, etc.)

PRENATAL SUPPORT PROGRAM

• Group vs. individual visits E.g.) Centering

• Nurse Family Partnership

• Other social supports

Options for Birth Providers/Settings

Options for birth setting

• Hospitals: delivery room, birthing suite

• Birth centers

• Home birth

Options for care providers

• Obstetrician

• Midwife

• (Doula)

Feeding Choices

• Breast/Chest vs. bottle feeding

• Advantages & disadvantages

FINAL PREPARATION

• Birth plan

• S/sx true labor – “go bag”

• Transportation/child/pet care

• Pediatrician

• Supplies/Car Seat

• Contraception