Chapter 12 – Nursing Management During Pregnancy

Preconception Care

• PURPOSE
  • Promote optimal health of birthing person & partner before conception to improve pregnancy outcomes.
  • Screen, identify, modify, or eliminate biomedical, behavioral, & social risks via counseling, prevention, & medical management.
• KEY COMPONENTS EVALUATED
  • Immunization status (e.g., MMR, varicella, Tdap, hepatitis B).
  • Underlying medical conditions (diabetes, hypertension, thyroid disorders, PKU, HIV/AIDS, seizure disorders, etc.).
  • Reproductive-health practices (contraceptive use, history of infertility, Pap/HPV status).
  • Sexuality & sexual practices (STI history, safer-sex counseling, partner assessment).
  • Nutrition & supplements (weight status, folic-acid intake ≥ 400\,\mu g/day, vitamin D, iron).
  • Lifestyle practices (tobacco, alcohol, illicit/recreational drug use, exercise habits, occupational hazards, environmental exposures).
  • Psychosocial issues (mental-health disorders, intimate-partner violence, social support, cultural or spiritual beliefs that influence care).
  • Medication & substance use (teratogens: isotretinoins, certain antiepileptics, ACE inhibitors, warfarin, lithium, etc.).
  • Support system & access to care (transportation, insurance, literacy, language, family resources).

Risk Factors for Adverse Pregnancy Outcomes

• PHARMACOLOGIC / CHEMICAL
  • Isotretinoins (Accutane): potent teratogen → craniofacial, cardiac, CNS anomalies.
  • Antiepileptic drugs (valproate, carbamazepine, phenytoin): ↑ neural-tube & cardiac defects.
  • Alcohol misuse: fetal alcohol spectrum disorders (growth restriction, CNS dysfunction, facial anomalies).
• METABOLIC / MEDICAL
  • Pre-existing diabetes (poor glycemic control) → congenital malformations, miscarriage, macrosomia.
  • Hypothyroidism (untreated): infertility, miscarriage, neuro-cognitive impairment in fetus.
  • Maternal phenylketonuria (PKU, if uncontrolled) → microcephaly, intellectual disability.
• INFECTIOUS & IMMUNOLOGIC
  • HIV/AIDS: vertical transmission risk; need antiretroviral therapy & delivery planning.
  • Rubella seronegativity: congenital rubella syndrome risk; vaccinate ≥ 1 mo before conception.
  • STI (chlamydia, gonorrhea, syphilis, HSV): miscarriage, PROM, neonatal infection.
• NUTRITIONAL & LIFESTYLE
  • Folic-acid deficiency: neural-tube defects (anencephaly, spina bifida).
  • Obesity (BMI ≥ 30): gestational diabetes, pre-eclampsia, macrosomia, C-section.
  • Smoking: IUGR, placental abruption, preterm birth.
  • Hypertension (chronic): placental insufficiency, stroke, superimposed pre-eclampsia.

The First Prenatal Visit

• GOALS
  • Establish trusting therapeutic relationship.
  • Begin continuous education for health promotion & pregnancy adaptation.
  • Detect & prevent current / potential problems (medical, psychosocial, obstetric).
  • Complete baseline data set: comprehensive history, physical exam, laboratory profile.
• EDUCATIONAL THEMES
  • Normal physiologic changes, danger signs, lifestyle modifications, nutrition, scheduling of future visits, available resources.

Comprehensive Health History

• REASON FOR SEEKING CARE
  • Suspicion of pregnancy, date of LMP, signs & symptoms, at-home urine test or serum \beta-hCG confirmation.
• PAST & PRESENT HISTORY
  • Medical–surgical illnesses, hospitalizations, family history (genetic, chronic diseases), allergies, immunizations, psychosocial factors.
• REPRODUCTIVE HISTORY
  1. Menstrual history (cycle, regularity, flow, discomforts, contraceptive use).
  2. Obstetric & gynecologic history (previous pregnancies, outcomes, infertility, STIs, Pap smears, uterine anomalies, surgeries).

Menstrual-History Details

• Typical cycle length & variability; age at menarche.
• Flow characteristics (amount, duration, presence of clots, dysmenorrhea).
• Date of Last Normal Menstrual Period (LNMP) → foundation for pregnancy dating.

Estimating Date of Birth – Nagele’s Rule

• STEPS
  1. Use first day of LNMP.
  2. Subtract 3 months.
  3. Add 7 days.
  4. Add 1 year (if applicable).
• EXAMPLE (given):
  \text{LNMP} = 11/21/07
  11/21/07-3 \text{ months}=8/21/07
  8/21/07+7 \text{ days}=8/28/07
  +1 \text{ year}=8/28/08 \Rightarrow \text{Estimated Date of Birth (EDB)}
• Alternative tools: gestational wheel, early ultrasound (most accurate < 13 weeks).

Obstetric Terminology & Gravidity/Parity Systems

• BASIC TERMS
  • Gravida: any pregnancy regardless of duration.
  • Primigravida: first pregnancy.
  • Secundigravida: second pregnancy.
  • Para: pregnancy ≥ 20 weeks (viability) ended with birth (alive or stillborn).
  • Nullipara: no pregnancy beyond viability.
  • Primipara: one delivery ≥ 20 weeks.
  • Multipara: ≥ 2 deliveries ≥ 20 weeks.
• GTPAL FRAMEWORK
  G = total pregnancies (including current)
  T = term births (≥ 37 0/7 weeks)
  P = preterm births (≥ 20 and < 37 weeks)
  A = abortions / miscarriages (< 20 weeks)
  L = living children (current count)

Physical Examination

• VITAL SIGNS: BP baseline for later comparison, HR, RR, temperature.
• SYSTEMIC REVIEW (head-to-toe)
  • Head & neck: thyroid enlargement, facial chloasma, gum hypertrophy.
  • Breasts: pigmentation, Montgomery glands, presence of masses.
  • Heart & lungs: functional murmurs, baseline adventitious sounds.
  • Abdomen: fundal height (after ~12 wks), fetal heart tones, scars.
  • Extremities: edema, varicosities, DVT signs.
• PELVIC EXAMINATION
  • Inspection of external genitalia → lesions, varicosities, discharge.
  • Speculum: cervical cytology, Gonorrhea/Chlamydia swabs.
  • Bimanual exam: uterine size/shape/position, adnexal masses.
  • Pelvic shape: gynecoid (ideal), android, anthropoid, platypelloid.
  • Pelvic measurements
  • Diagonal conjugate: sacral promontory to inferior symphysis ≈ 11.5–13 cm.
  • True (obstetric) conjugate (estimated): \text{Diagonal} - 1.5\,\text{cm}.
  • Ischial-tuberosity diameter: transverse outlet ≥ 10.5 cm.

Initial Laboratory Profile

• Urinalysis (protein, glucose, ketones, infection).
• Complete blood count (baseline anemia or infection, platelets).
• Blood type & Rh, antibody screen (Rh-negative → Rhogam planning).
• Rubella titer (immune if \ge 1:10 hemagglutination).
• Hepatitis B surface antigen.
• HIV antibody (opt-out consent).
• Syphilis testing (VDRL/RPR, confirm w/ FTA-ABS).
• Cervical cytology as indicated (age ≥ 21, interval compliance).
• Early obstetric ultrasound (dating, viability, location).

Follow-Up Visit Schedule & Content

• TIMING
  • Every 4 weeks: conception → 28 weeks.
  • Every 2 weeks: 29 → 36 weeks.
  • Weekly: 37 weeks → birth.
• ASSESSMENT AT EACH VISIT
  • Weight gain & BP vs. baseline.
  • Urine dipstick: protein, glucose, ketones, nitrites.
  • Fundal height in cm ≈ gestational weeks (from 20–36 weeks).
  • Fetal heart rate (Doppler 110–160 bpm) & rhythm.
  • Quickening / daily fetal-movement perception.
  • Review danger signs (vaginal bleeding, gush of fluid, persistent vomiting, severe headache/visual changes, decreased FM, s/s infection, pre-eclampsia triad, preterm contractions).
  • Ongoing education, psychosocial support, plan of care updates.

Assessment of Fetal Well-Being (Diagnostic Testing)

• IMAGING & BIOPHYSICAL
  • Ultrasonography: viability, dating, anatomy survey, placental positioning, AFI.
  • Doppler flow studies: placental & fetal circulation (IUGR, isoimmunization, HTN).
  • Biophysical profile (BPP) score 0–10 (NST + ultrasound of fetal breathing, movement, tone, AFI).
• MATERNAL SERUM / MARKER SCREENING
  • Alpha-fetoprotein (AFP) or quad screen (AFP, hCG, unconjugated estriol, inhibin-A) @ 15–18 wks → NTD ↑ AFP; Down syndrome pattern.
  • First-trimester combined test: PAPP-A, hCG, nuchal translucency.
• INVASIVE GENETIC TESTS
  • Chorionic villus sampling (CVS) 10–13 wks: placental chorion biopsy.
  • Amniocentesis ≥ 15 wks: karyotype, AFP, fetal lung maturity later.
  • Percutaneous umbilical blood sampling (PUBS): fetal anemia, infections.
• FUNCTIONAL TESTS IN 3RD TRIMESTER
  • Non-stress test (NST): reactive = ≥ 2 accelerations \ge 15 bpm × 15 s in 20 min.
  • Contraction stress test (CST): late decels with contractions indicate uteroplacental insufficiency.

Common Pregnancy Discomforts & Nursing Management

First Trimester (0–13 weeks)

• Urinary frequency / incontinence: void q2 h, Kegel exercises, limit fluids before bedtime.
• Fatigue: rest periods, balanced diet, moderate exercise.
• Nausea & vomiting: small frequent meals, avoid triggers, ginger, vitamin B6.
• Breast tenderness: supportive bra, avoid soap on nipples.
• Constipation: ↑ fluid, fiber, mild exercise, stool softeners if prescribed.
• Nasal stuffiness, epistaxis: humidifier, saline drops (estrogen-induced edema).
• Cravings & Pica: assess nutritional deficits, reassure occasional cravings.
• Leukorrhea: cotton underwear, perineal hygiene, report odor/pruritus.

Second Trimester (14–27 weeks)

• Backache: pelvic tilt exercises, side-lying, supportive shoes.
• Varicosities (legs/vulva): elevate legs, left-side rest, compression stockings.
• Hemorrhoids: sitz baths, topical ointments, avoid constipation.
• Flatulence/bloating: regular meals, avoid gas-forming foods, exercise.
• NOTE: Urinary frequency generally decreases as uterus rises into abdomen.

Third Trimester (28 weeks → term)

• Recurrence of 1st trimester urinary frequency as fetus drops.
• Shortness of breath/dyspnea: sleep semi-Fowler with pillows, slow respiration.
• Heartburn (pyrosis): small meals, avoid spicy/fatty foods, sit upright after meals, antacids per provider (avoid sodium bicarbonate).
• Dependent edema: elevate feet, side-lying rest, avoid prolonged standing.
• Braxton Hicks contractions: hydration, rest, change positions; differentiate from true labor.

Health-Promotion & Self-Care Guidance

• Personal hygiene: daily bathing, mild soap, attention to perineum (↑ leukorrhea).
• Avoid hyperthermia: no hot tubs (> 38.9°C) or saunas.
• Dental care: periodontal disease linked to preterm birth; prophylaxis safe with lidocaine.
• Breast care: no soap on nipples; breast shells for inverted nipples.
• Clothing: loose, non-restrictive, low-heeled shoes.
• Exercise: moderate, low-impact ≥ 30 min most days; avoid high-risk sports, supine positions after 20 wks.
• Sleep & rest: left lateral position enhances uteroplacental perfusion; pillows for support.
• Sexuality: generally safe; counsel re contraindications (threatened preterm labor, placenta previa, PROM).
• Employment: assess ergonomic stress, chemical exposure, prolonged standing (> 4 h) → rest breaks.
• Travel: seat belt beneath abdomen & across shoulder; air travel generally up to 36 wks; move q2 h to prevent DVT.
• Immunizations: inactivated vaccines safe (influenza, Tdap between 27–36 wks); avoid live vaccines (MMR, varicella, nasal flu).
• Medications: use only practitioner-approved; review FDA pregnancy categories / PLLR labeling.

Preparation for Labor, Birth, & Parenthood

Perinatal Education Programs

• Lamaze (psychoprophylactic): controlled breathing, relaxation, focal points to reduce pain perception.
• Bradley (partner-coached): emphasis on husband/partner involvement, deep abdominal breathing, nutrition, exercise.
• Dick-Read (natural childbirth): education reduces fear–tension–pain cycle; slow abdominal breathing.
• Additional classes: infant CPR, breastfeeding, parenting, sibling preparation.

Birth Settings & Care Providers

• Settings
  • Hospital delivery room or LDRP suite (labor–delivery–recovery–postpartum).
  • Freestanding birth center (home-like, midwifery model, emergency transfer plan).
  • Home birth (low-risk clients, certified professional midwife, emergency backup).
• Providers
  • Obstetrician (medical/surgical expertise, operative birth privileges).
  • Certified nurse-midwife (physiologic-focused, collaborative protocols).
  • Doula (continuous labor support, non-clinical, improves outcomes).

Feeding Choices & Education

• Breastfeeding
  • Advantages: optimal nutrition, antibodies (IgA), bonding, reduced SIDS, maternal weight loss, ↓ ovarian/breast CA.
  • Disadvantages: nipple pain, lifestyle adjustments, contraindications (HIV in U.S., galactosemia, some medications).
• Bottle-feeding
  • Advantages: shared feeding responsibility, flexible scheduling, easier maternal medication use.
  • Disadvantages: costly, ↑ infection & allergy risk, no maternal physiologic benefits.
• Teaching: latch techniques, storage guidelines, formula preparation hygiene, feeding cues.

Ethical, Philosophical, & Practical Considerations

• Respect for autonomy & informed consent integral to diagnostic testing (CVS, amnio, genetic screening).
• Justice: equitable access to preconception & prenatal care reduces health disparities among marginalized populations.
• Non-maleficence: diligent medication review prevents teratogenic harm.
• Beneficence: nurse advocates for resources (WIC, social work) to improve outcomes.
• Cultural humility: incorporate traditional beliefs (e.g., hot–cold theory, postpartum confinement) into plan when safe.

Key Formulas & Numerical References

• Nagele’s rule (EDB): \text{LNMP} - 3 \text{ months} + 7 \text{ days} + 1 \text{ year}.
• Fundal height (cm) ≈ gestational age (weeks) from 20–36 wks (± 2 cm).
• Reactive NST: ≥ 2 accelerations \ge 15 bpm, 15 s duration within 20 min.
• BPP scoring: 8–10 = normal, 6 = equivocal, ≤ 4 = abnormal (delivery indicated).
• Normal pregnancy weight gain (singleton)
  • Underweight (BMI < 18.5): 28–40 lb (12.7–18.1 kg).
  • Normal (BMI 18.5–24.9): 25–35 lb (11.3–15.9 kg).
  • Overweight (BMI 25–29.9): 15–25 lb (6.8–11.3 kg).
  • Obese (BMI ≥ 30): 11–20 lb (5–9 kg).

Sample Exam-Style Questions & Clarifications

• Multipara definition: ≥ 2 pregnancies ≥ 20 weeks (NOT first-time pregnant).
• Follow-up visit frequency: at 24 weeks → every 4 weeks, not 2.
• Second-trimester unusual symptom: urinary frequency (should have improved).

Connections & Reinforcement

• Builds upon earlier anatomy/physiology lectures (hormonal changes, uteroplacental perfusion) & nutrition principles (folate metabolism).
• Diagnostic testing correlates with genetics module (trisomy screening) & neonatology (impact of IUGR, prematurity).
• Ethical content echoes nursing-ethics fundamentals (principles, cultural competence).
• Real-world relevance: CDC data on maternal mortality → emphasis on early risk identification & continuous care.

Quick Reference – Danger Signs to Teach

• First trimester: severe vomiting, abdominal cramping + bleeding (ectopic, miscarriage), fever > 38°C, chills.
• Second trimester: gush of fluid (PROM), vaginal bleeding, absence of fetal movement > 12 h, severe back/abd pain.
• Third trimester: visual disturbances, persistent headache, upper-abd pain (RUQ), edema of face/hands, seizures, fever, decreased FM, signs of labor pre-36 wks.