Comprehensive Preconception and Prenatal Care Notes

Preconception and Prenatal Care Notes

• Preconception care and diagnostic testing
  • Amniocentesis
  • Biophysical profile
  • Chorionic villus sampling (CVS)
  • Natural childbirth
  • Perinatal education
  • Preconception care

Goals of Preconception Care

• Promote the health and well-being of a woman and her partner before pregnancy
• Identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management intervention
• This should begin prior to conception

Risk Factors for Adverse Pregnancy Outcomes

• Isotretinoin
• Alcohol misuse (leading cause of intellectual disability in the United States)
• Antiepileptic drugs
• Diabetes (preconception)
• Folic acid deficiency (prevents neural tube defects;/+ alpha fetoprotein)
• HIV/AIDS
• Hypothyroidism
• Maternal phenylketonuria
• Rubella seronegativity
• Obesity
• Oral anticoagulants
• STI
• Smoking

Preconception Care Components

• Immunization status
• Underlying medical conditions
• Reproductive health care practices
• Sexuality and sexual practices
• Nutrition
• Lifestyle practices
• Psychosocial issues
• Medication and drug use (safe with pregnancy?)
• Support system

First Prenatal Visit

• Establishment of trusting relationship
• Focus on education for overall wellness
• Detection and prevention of potential problems
• Comprehensive health history, physical examination, and laboratory tests

Comprehensive Health History

• Reason for seeking care
  • Suspicion of pregnancy
  • Date of last menstrual period
  • Signs and symptoms of pregnancy
  • Urine or blood test for hCG
• Past medical, surgical, and personal history
• Woman’s reproductive history: menstrual, obstetric, and gynecologic history

Menstrual History

• Menstrual cycle details:
  • Age at menarche
  • Days in cycle
  • Flow characteristics
  • Discomforts
  • Use of contraception

Date of LMP and Pregnancy Dating

• Date of last menstrual period (LMP)
• Calculation of estimated or expected date of birth (EDB) or delivery (EDD)
• Nagele’s rule
• Use first day of LNMP
  • LNMP: 11/21/07
  • Subtract 3 months: 8/21/07
  • Add 7 days: 8/28/07
  • Add 1 year: 8/28/08 = EDB
• Gestational or birth calculator or wheel
• Ultrasound is the best method of dating a pregnancy

Obstetric History

• Gravida I (primigravida): first pregnancy
• Gravida II (secundigravida): second pregnancy, etc.
• Gravida: a pregnant woman
• Primipara: one birth after a pregnancy of at least 20 weeks ("primip")
• Multipara: two or more pregnancies resulting in viable offspring ("multip")
• Nullipara: no viable offspring; para 0
• Para: a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more

Terminology (G, T, P, A, L)

• G (gravida): the current pregnancy
• T (term births): the number of pregnancies ending >37 weeks’ gestation, at term
• P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks
• A (abortions): the number of pregnancies ending before 20 weeks or viability
• L (living children): number of children currently living

Physical Examination

• Vital signs
• Head-to-toe assessment
  • Head and neck
  • Chest
  • Abdomen, including fundal height if appropriate
  • Extremities
• Pelvic examination
  • Examination of external and internal genitalia
  • Bimanual examination
  • Pelvic shape: gynecoid, android, anthropoid, platypelloid
  • Pelvic measurements: diagonal conjugate, true (obstetric) conjugate, and ischial tuberosity

A B (illustrative) – Pelvimetry

• The pelvic capacity enables the fetus to pass through the birth canal
• Pelvimetry can help a clinician decide whether to offer an elective cesarean section due to risk of cephalopelvic disproportion
• Timing: 37–39 weeks gestation
• Adequate pelvis inlet = >12 cm

Laboratory Tests

• Urinalysis
• Complete blood count
• Blood typing
• Rh factor
• Rubella titer
• Hepatitis B surface antigen
• HIV, VDRL, and RPR testing
• Cervical smears
• Ultrasound

Follow-Up Visits

• Visit schedule:
  • Every 4 weeks up to 28 weeks
  • Every 2 weeks from 29 to 36 weeks
  • Every week from 37 weeks to birth
• Assessments:
  • Weight and BP compared to baseline values
  • Urine testing for protein, glucose, ketones, and nitrites
  • Fundal height
  • Quickening/fetal movement
  • Fetal heart rate
• Teaching: danger signs

Fundal Height

• A fundal height measurement helps determine if a baby is small for gestational age
• Measurement is the distance in centimeters from the pubic bone to the top of the uterus
• After 24 weeks, fundal height often matches the number of weeks pregnant (± 2 cm)

Assessment of Fetal Well-Being

• Ultrasonography
• Doppler flow studies (blood flow)
• Alpha-fetoprotein analysis (neural tube defects)
• Marker screening tests (genetics)
• Nuchal translucency screening (chromosomal abnormality)
• Amniocentesis (physical abnormalities)
• Chorionic villus sampling (CVS) – chromosomal abnormalities and certain other genetic problems
• Percutaneous umbilical blood sampling (PUBS) – sampling of the baby’s blood to evaluate and treat specific fetal problems
• Nonstress test; contraction stress test
  • Nonstress test: measures the heart rate of the fetus in response to its own movements
  • Contraction stress test: determine if the fetus can handle contractions during labor and receive adequate oxygen
• Biophysical profile: checks baby’s health via body movements, muscle tone, breathing movements, amniotic fluid, and heartbeat (real-time ultrasound)

Kick Counts

• Purpose: monitor fetal movements to detect potential distress
• Timing: third trimester (weeks 28–40); lack of movement may indicate distress or problems
• Typical: ten movements (kicks, flutter, or rolls) in one hour
• Steps to count:
  • Choose a time when distracted least or when fetus moves normally
  • Get comfortable (lie on left side or sit semi-Fowler)
  • Place hands on belly
  • Start timer
  • Count each kick until 10
  • Note how many minutes it took to reach 10
  • Do daily after 28 weeks (26 weeks if high risk)

First Trimester Discomforts

• Urinary frequency or incontinence
• Fatigue
• Nausea and vomiting
• Breast tenderness
• Constipation
• Nasal stuffiness, bleeding gums, epistaxis
• Cravings
• Leukorrhea

Second Trimester Discomforts

• Backache
• Varicosities of the vulva and legs
• Hemorrhoids
• Flatulence with bloating

Third Trimester Discomforts

• Return of first trimester discomforts
• Shortness of breath and dyspnea
• Heartburn and indigestion
• Dependent edema
• Braxton Hicks contractions

Nursing Management to Promote Self-Care

• Personal hygiene
• Avoidance of saunas and hot tubs
• Perineal care
• Dental care
• Breast care
• Clothing
• Exercise
• Sleep and rest
• Sexual activity and sexuality
• Employment
• Travel – Zika Virus
• Immunizations and medications

Preparation for Labor, Birth, and Parenthood

• Perinatal education
• Childbirth education
  • Lamaze (psychoprophylactic) method: focus on breathing and relaxation techniques
  • Bradley (partner-coached childbirth) method: focus on exercises and slow, controlled abdominal breathing
  • Dick-Read (natural childbirth) method: focus on fear reduction via knowledge and abdominal breathing techniques

Preparation for Labor, Birth, and Parenthood – Birth Settings and Care Providers

• Options for birth setting:
  • Hospitals: delivery room, birthing suite
  • Birth centers
  • Home birth
• Options for care providers:
  • Obstetrician
  • Midwife
  • Doula

Preparation for Labor, Birth, and Parenthood – Breastfeeding, Bottle Feeding

• Breast-feeding: advantages and disadvantages
• Colostrum: your first milk that lasts between two and four days after birth
• Transitional milk: begins approximately four days after birth and lasts about two weeks; highly concentrated with nutrients and antibodies
• Mature milk: lasts from approximately 14 days after birth until you finish producing milk; provides all nutrients
• Oxytocin is released with breastfeeding
• Bottle feeding: advantages and disadvantages
• Teaching feeding choices

Final preparation for labor and birth

• (Content summarized under the above topics; emphasizes preparation and education for labor and birth)

Notable Formulas and Numbers

• Nagele’s rule for estimating EDB/EDD:
  • \text{EDB} = \text{LNMP} - 3 \text{ months} + 7 \text{ days} + 1 \text{ year}
  • Example: LNMP = 11/21/2007 → EDB = 8/28/2008
  • Step sequence: LNMP 11/21/07 → subtract 3 months = 8/21/07 → add 7 days = 8/28/07 → add 1 year = 8/28/08
• Ultrasound dating: Ultrasound is the best method of dating a pregnancy
• Pelvic inlet measurement for adequacy: > 12 cm
• Fundal height typically correlates with gestational age after 24 weeks, within ±2 cm

Quick Reference: Common Terms

• G = Gravida (current pregnancy)
• T = Term births (>37 weeks)
• P = Preterm births (>20 weeks but <37 weeks)
• A = Abortions (<20 weeks)
• L = Living children
• Primipara = one birth after a pregnancy of at least 20 weeks
• Nullipara = no viable offspring (para 0)
• Para = number of pregnancies resulting in viable offspring (births at ≥20 weeks)

Important Contacts and Timing

• Follow-up intervals are designed to monitor maternal weight, blood pressure, urine findings, fundal height, fetal movements, and fetal heart rate
• Education on danger signs is an ongoing component of prenatal care

Summary of Real-World Relevance and Implications

• Preconception care aims to prevent adverse outcomes by optimizing health before conception (e.g., managing diabetes, ensuring folic acid sufficiency, updating immunizations)
• Early dating and careful obstetric history improve risk stratification and planning (e.g., use ultrasound dating to confirm dating, plan for potential cesarean if cephalopelvic disproportion risk is high)
• Understanding labor preparation and birth settings helps align expectations with available resources and personal preferences
• Breastfeeding education and support impact infant nutrition, maternal health, and long-term outcomes
• Ethical and practical implications involve informed decision-making, access to perinatal education, and individual risk management for maternal and fetal health