Ch.14 Nursing Care of the Family During Pregnancy lecture notes (completed)

Diagnosis and Confirmation of Pregnancy

• Presumptive (Subjective) Indicators: These are complaints and symptoms reported by the client themselves. They are not definitive proof of pregnancy as they can be caused by other conditions.

  • Nausea and vomiting.

  • Missed menstrual cycle (amenorrhea).

  • Fatigue.

• Probable (Objective) Indicators: These are findings observed by the healthcare provider during an examination.

  • Hegar sign: Softening and compressibility of the lower uterine segment.

  • Goodell sign: Softening of the cervical tip.

  • Chadwick sign: Violet-bluish color of the vaginal mucosa and cervix.

• Positive (Objective) Indicators: These findings indicate definitive proof of pregnancy.

  • Fetal heart tones heard on Doppler.

  • Visualization of the fetus on ultrasound ($u/s$).

  • Palpation of fetal parts by the provider.

Estimating Date of Birth (EDB)

• Naegele Rule: This is the standard calculation used to determine the EDB based on the first day of the client’s Last Menstrual Period ($LMP$).

  • Formula: $\text{EDB} = \text{LMP} - 3 \text{ months} + 7 \text{ days} + 1 \text{ year}$ (year added depending on the month).

  • If the date falls toward the end of the month, apply the same rule but ensure the month is adjusted forward if the 7-day addition pushes into a new month.

• Other Tools:

  • Pregnancy wheel / Gestation calculator.

  • Early ultrasound ($u/s$) measurements, provided they are obtained prior to 12 weeks of gestation.

• Duration of Pregnancy Constants:

  • Total days: $280\text{ days}$.

  • Total weeks: $40\text{ weeks}$.

  • Lunar months: $\sim 10\text{ months}$.

• Practice Calculations (Using Naegele Rule):

  • LMP December 1, 2025: $\text{September 8, 2026}$.

  • LMP January 10, 2026: $\text{October 17, 2026}$.

  • LMP December 28, 2025: $\text{October 5, 2026}$.

  • LMP October 21, 2025: $\text{July 28, 2026}$.

Adaptation to Pregnancy

• Maternal Adaptation:

  • Accepting the pregnancy.

  • Identifying with the role of a parent.

  • Establishing a relationship with the fetus.

  • Preparing for the birth process.

• Partner Adaptation:

  • The process of the partner accepting the pregnancy and preparing for their role.

• Inclusive Care: Special consideration and adaptation to pregnancy for same-sex couples and clients identifying as LGBTQIA.

Obstetrical Terminology and Calculations

• Core Definitions:

  • Gestation: The period of intrauterine development from conception through birth.

  • Gravida (G): A woman who is pregnant or the total number of pregnancies a woman has had.

    • Multiple fetuses (twins, triplets, etc.) count as one single pregnancy/gravida.

  • Parity (P): The number of pregnancies in which the fetus or fetuses reached $20\text{ weeks}$ of gestation.

    • A delivery of two or more fetuses after $20\text{ weeks}$ still counts as parity 1.

• Specific Obstetrical Terms:

  • Nulligravida: A woman who has never been pregnant.

  • Primigravida: A woman pregnant for the first time.

  • Multigravida: A woman who has had two or more pregnancies.

  • Nullipara: A woman who has not completed a pregnancy with a fetus reaching $20\text{ weeks}$.

  • Primipara: A woman who has completed one pregnancy with a fetus reaching $20\text{ weeks}$.

  • Multipara: A woman who has completed two or more pregnancies to $20\text{ weeks}$ or more.

  • Antepartum: Before birth; the period from conception to the onset of labor.

  • Intrapartum: During birth; the period from the onset of labor until the delivery of the placenta.

  • Postpartum: After birth.

• Gestational Definitions:

  • Preterm: A pregnancy that has reached $20\text{ weeks}$ but ends before completion of $37\text{ weeks}$.

  • Late Preterm: $34\text{ weeks 0 days } \text{to } 36\text{ weeks 6 days}$.

  • Early Term: $37\text{ weeks 0 days } \text{to } 38\text{ weeks 6 days}$.

  • Full Term: 37 weeks onward

  • Late Term: $41\text{ weeks 0 days } \text{to } 41\text{ weeks 6 days}$.

  • Post Term: $42\text{ weeks 0 days } \text{and beyond}$.

  • Viability: The capacity to live outside the uterus (usually considered $\sim 22\text{ to } 25\text{ weeks}$).

  • Stillbirth/Stillborn: The birth of a baby who has died after $24\text{ weeks}$ of pregnancy.

  • Abortion/Miscarriage: Pregnancy loss before $20\text{ weeks}$ (spontaneous or induced).

GTPAL Practice and Scenarios

• GTPAL System:

  • G: Gravida (number of pregnancies).

  • T: Term (pregnancies reaching $37\text{ weeks 0 days}$ and beyond).

  • P: Preterm (pregnancies reaching $20\text{ weeks}$ but ending before $37\text{ weeks 0 days}$).

  • A: Abortion/Miscarriage (pregnancies ending before $20\text{ weeks}$).

  • L: Living children.

• Practice Exercise Cases:

  1. JD: Currently 8 weeks pregnant ($1^{st} \text{ prenatal visit}$). Has a 9-year-old delivered at 38 weeks and a 4-year-old delivered at 36 weeks.

     • Result: $G3, T1, P1, A0, L2$

  2. RM: Has a 10-year-old delivered at 37 weeks, an 8-year-old delivered at 38 weeks, twins delivered at 34 weeks, and a miscarriage at 12 weeks. Not currently pregnant.

     • Result: $G4, T2, P1, A1, L4$

  3. RC: Currently pregnant (second time) at 24 weeks. The first pregnancy ended at 21 weeks due to a car accident.

     • Result: $G2, T0, P1, A0, L0$

Prenatal Care (PNC) Management

• Trimester Timeline:

  • 1st Trimester: Week 1 through 13.

  • 2nd Trimester: Week 14 through 26.

  • 3rd Trimester: Week 27 through 40.

• Traditional Visit Schedule:

  • Every 4 weeks until $28\text{ weeks}$ .

  • Every 2 weeks from $28\text{ to } 36\text{ weeks}$.

  • Every week from $36\text{ weeks}$ until birth.

• Initial Visit Components:

  • Prenatal Interview: Includes reasons for seeking care, current pregnancy status, and detailed histories (OB/GYN, general health, nutrition, medication, mental health).

  • Screening: Screening for Intimate Partner Violence (IPV).

  • Physical Exam: Assessment of all systems and initial fundal height.

  • Initial Labs: CBC with differential (Hgb/Hct, WBC), ABO typing and Rh factor (including antibody screen), Urinalysis and Culture (to check for asymptomatic bacteriuria), Rubella titer, STI Panel (VDRL, HIV, Hepatitis B), GC/CT smears, Pap test, and Ultrasound if dates are unsure.

  • Teaching: Self-management, nutrition, hygiene, exercise, breastfeeding preparation.

• Follow-up (Consequent) Visit Components:

  • Data collection and vital signs.

  • Weight checks and Urinalysis (dipstick). [THESE TWO ARE MANDATORY]

  • Physical exam and fundal height measurement.

  • Fetal assessment (Heart tones and movement).

Physical and Fetal Assessment

• Abdominal Assessment Technique: Position the client supine with a pillow under the head and a wedge under the right hip (to prevent supine hypotension).

• Fundal Height: Measurement is taken from the symphysis pubis to the top of the fundus. This is typically done during the second trimester and beyond.

• Fetal Heart Tones: Assessed using a Doppler starting at approximately $12\text{ weeks}$.

• Quickening: Maternal perception of fetal movement, typically felt between $16\text{ and } 20\text{ weeks}$.

• Landmarks in Pregnancy:

  • 13 weeks: The uterus becomes an abdominal organ.

  • 16 weeks: Fundus is midway between the symphysis pubis and the umbilicus.

  • 20-22 weeks: Fundus is at the level of the umbilicus.

  • 26-28 weeks: Fundus is midway between the umbilicus and the xiphoid process. Ultrasound is needed to confirm a big baby above 9 lbs.

  • 28-32 weeks: The fundal height in centimeters is approximately equal to the gestational weeks ($\pm 2\text{ cm/weeks}$).

  • 36 weeks: Fundus reaches the xiphoid process.

  • 38-40 weeks: "Lightening" occurs; the fundal height drops as the fetus descends into the pelvis.

Intimate Partner Violence (IPV)

• Definition: Behavior by an intimate or ex-partner resulting in physical, sexual, or psychological harm (aggression, coercion, abuse, and controlling behavior).

• Statistics: Approximately $300,000$ pregnant women are affected by IPV in the U.S.

• Patterns of Violence During Pregnancy:

  1. Commencement of violence with the onset of pregnancy.

  2. Violence before and during pregnancy with no change in intensity.

  3. Termination of violence during pregnancy.

  4. No violence before or during pregnancy.

• Nursing Assessment Strategies:

  • Gain the client's trust and ask direct questions.

  • Crucial: Interview the client away from their partner.

  • Look for injuries to the face, breasts, abdomen, and buttocks (bruises or fractures in various stages of healing).

• Nursing Intervention (A-B-C-D-E-S):

  • A: Reassure the client she is Alone no longer.

  • B: Express the Belief that violence is unacceptable.

  • C: Ensure Confidentiality.

  • D: Use Descriptive Documentation (use exact quotes from the client).

  • E: Educate on options and community resources.

  • S: Focus on Safety; the most dangerous time is when the woman decides to leave the relationship.

Labs at initial visit [Table 14.2]

• CBC with diff, hgb/hct, WBC

• ABO – type & Rh factor (antibody screen)

• Urine - analysis & c/s (asymptomatic bacteriuria)

• Rubella titer

• STI panel: VDRL, HIV, Hep B

• GC/CT smears

• Pap test

• Ultrasound (if unsure of dates)

Third Trimester Laboratory Tests and Immunizations

• At 24-28 Weeks:

  • Glucose screening for gestational diabetes. Done earlier if patient has family history of Diabetes.

• At 28 Weeks:

  • Repeat Labs: CBC, RPR (syphilis), HIV, Hepatitis B.

  • Quad screen (for Trisomy testing).

  • MSAFP (Maternal Serum Alpha-Fetoprotein) for neural tube defects.

  • Immunizations: Rhogam (if Rh-negative), Tdap.

• At 35-37 Weeks:

  • Group Beta Strep (GBS) swab.

• General Immunization Guidelines:

  • Hepatitis B and Flu vaccines are safe. Avoid other live virus immunizations.

Education for Self-Management

• Nutrition: Emphasize prenatal vitamins, increased fluid intake, and managing Pica (craving non-food items).

• Foods to Avoid:

  • Fish: Shark, swordfish, tilefish, king mackerel (due to high mercury levels); avoid smoked or raw seafood.

  • Dairy/Other: Soft cheeses (brie, feta, queso fresco), uncooked eggs, raw sprouts, unpasteurized milk.

  • Meat: Unheated hot dogs or deli meats.

  • Alcohol: Completely avoid wine and all other alcohol.

• Activity:

  • Exercises: Kegel exercises to strengthen the pelvic floor.

  • Guidance on physical activity, rest, relaxation, travel, and sexual activity.

• Hygiene: Maintain oral health and regular bathing; focus on preventing infections (UTIs and URTIs).

• Preparation for Breastfeeding: Education on breastfeeding and the presence of colostrum.

Discomforts and Complications

• Common Discomforts by System (Refer to Table 14.3, pg. 286-288):

  • Breasts, Genitourinary, Integument, Circulatory, Musculoskeletal, and Gastrointestinal systems.

• Potential Complications (Refer to Table 14.4, pg. 289): Signs of potential complications vary by the 1st, 2nd, and 3rd trimesters.