LESSON 1-6
PRENATAL CARE DURING PREGNANCY

Introduction

The prenatal period is a preparatory time for the mother to prepare herself both physically and psychologically. It is a time of immense anxiety, excitement, and learning. The best way to ensure the health of both the expectant mother and her infant is through early and attentive prenatal care. Close supervision will allow health care professionals to identify and possibly treat maternal disorders that may have been preexistent or developed during the pregnancy. This lesson will include what occurs during the prenatal visits.

Terms and Definitions

Abortion. Termination of pregnancy before the fetus is viable and capable of extrauterine existence.

Conjugate. An important diameter of the pelvis, measured from the center of the promontory of the sacrum to the back of the symphysis pubis.

Ischial Spines. Two relatively sharp, bony projections protruding into the pelvic outlet from the ischial bone that form the lower lateral border of the pelvis. They are used when determining the progress of the fetus down the birth canal.

Ischial Tuberosities. A major bony, sitting support; important in measuring a transverse diameter of the pelvis.

Miscarriage. Spontaneous abortion; lay term usually referring specifically to the loss of the fetus between the fourth month and viability.

Placenta Abruptio. Premature separation of a normally, implanted placenta.

Placenta Previa. A placenta that is implanted in the lower uterine segment so that it adjoins or covers the internal os of the cervix.

Term Pregnancy. A gestation of 38 to 42 weeks.

Toxoplasmosis. A congenital disease characterized by lesions of the central nervous system which may lead to blindness, brain defects, and death.

 Principles of Prenatal Care

a. Definition. Antepartal or prenatal care refers to the medical and nursing supervision and care given to the pregnant patient during the period between conception and the onset of labor.

b. Objectives of Prenatal Care. During the initial visit, the objectives are directed toward confirming a diagnosis of pregnancy and beginning the process of data collection to act as a basis for ongoing prenatal care. These objectives include:

(1) Prevention of complication.

(2) Modification of those complications that may develop.

(3) Support of the patient's goal to carry the infant to term and deliver a healthy baby.

(4) Education of the mother-to-be and her family for the parenting role.

(5) Inclusion of the family as a whole in the concept of "family-centered maternity care."

c. Health Care Professionals. Health care professionals involved in the administration of the prenatal care includes:

(1) Physicians. They are primarily involved in diagnosing normal and abnormal conditions associated with the childbearing cycle.

(2) Nursing personnel. Nursing personnel includes the nurse practitioners, clinical nurse specialists, registered nurses, and licensed practical nurses. Nursing personnel serves as teachers, counselors, and resource personnel. They have the responsibility to develop and implement nursing care plans.

(3) Others. Other health care personnel that are involved in prenatal care are:

(a) Dietitians.

(b) Laboratory technicians.

(c) Social services.

(d) Occupational therapists.

(e) Similar support personnel.

d. Choice of Health Care Professionals. The pregnant patient is responsible to choose the type of individual she prefers to consult for prenatal supervision and care. She may choose a private obstetrician, family practice physician, clinic with no control over which physician provides the care, or a nurse midwife. The primary concern is whether the individual she chooses meets her goals, desires, and expectations.

e. Early Care. Early, competent care is essential for the patient to avoid unnecessary risks to herself and her fetus. Initial Prenatal Visit

Prenatal Questionnaire

a. The initial prenatal visit should be scheduled at the first signs of pregnancy. This is usually shortly after the second menstrual cycle is missed. Depending on where the care is to be given, the first prenatal visit may not be scheduled until after a positive urine pregnancy test is documented.

b. The initial prenatal visit may be particularly stressful to the patient. Some patients may be anxious about the nature of exams and tests to be done during the visit. The pregnancy may have been unplanned, there may be already existing financial or family problems, or some patients may have had unpleasant experiences with previous pregnancies. The presence of one or more of these problems may serve to heighten the emotional content of the visit.

c. Setting a comfortable climate is very important to the patient. The patient's first impression and initial reception will influence how she may comply with the instructions given during pregnancy. If treated with a true concern as an individual, she will be more inclined to follow instructions. If the patient is rushed with little concern for her as an individual, she may decide not to return. A cordial, respectful environment in which the patient feels like a person is a necessity for every visit.

d. A thorough medical/obstetrical history is obtained. The history is essentially a screening tool that identifies the factors that may detrimentally affect the course of pregnancy. This process involves interviewing the patient and possibly having the patient to complete a questionnaire to obtain the following information:

(1) Past medical history of the patient's mother and father (for example, hypertension, diabetes, and tuberculosis)

(2) Family illnesses (that is, diabetes, mental illness, and bleeding disorders).

(3) Obstetric/gynecologic record.

(a) Last menstrual period (LMP) and menstrual history (for example, last regular cycle and spotting).

(b) Contraceptive history (Were birth control pills used? Did the patient become pregnant immediately after cessation of pills? How long after cessation of pills?

(c) Reproductive history (for example, number of previous pregnancies and their outcomes, complications).

(d) Exposure or treatment for any sexually transmitted diseases (STDs).

(e) Problems with the current pregnancy (for example, bleeding, nausea, and headaches).

(4) Present medical condition of the patient (for example, hypertension, diabetes, medications presently taking, and any drug allergies).

e. Physical examination. After a complete history is obtained, the patient is prepared for a through physical examination.

(1) Vital signs are taken to include:

(a) Temperature, pulse, respiration, and blood pressure.

(b) Fetal heart tones. Document if obtained with a doppler or fetoscope.

(2) Evaluate height, normal weight, and present weight.

(3) Obtain urine specimen. This should be obtained before the patient undresses for the pelvic examination.

(a) On the initial visit, a complete urinalysis is done.

(b) On subsequent visits, a urine specimen will be dipsticked for albumin and glucose.

(c) Additional testing will be done only if there are indications of toxemia of pregnancy or diabetes mellitus.

(4) Prepare patient for a pelvic examination, if performed.

(a) A pelvic examination is performed to confirm the pregnancy and to determine gestation. An examiner will look for signs of pregnancy--Chadwick's sign (color of cervix), Goodell's sign (softening of tip of cervix), and Hegar's sign (softening of the region between the body of the uterus and cervix). He will also evaluate the size of the uterine and the fundal height.

(b) Estimate of pelvic size. The examiner evaluates the position of the ischial spines and tuberosities. He evaluates diagonal conjugate to estimate pelvic canal size and whether it will allow passage of the fetus at the time of birth.

 Note

One vaginal birth is not proof of adequate pelvic space for all subsequent deliveries.

(c) Palpation of pelvic contents is done to identify any abnormal masses or tumors.

(d) Nursing responsibilities.

1 Assemble necessary equipment (speculum, lubricant, spatula for cervical scraping, glass slide, culture tube with sterile cotton-tipped applicator, exam gloves, and exam light).

2 Have the patient empty her bladder so she is more comfortable. It is easier for the examiner to evaluate the size of the uterus on an empty bladder.

3 Have the patient to remove her clothing and to put on a patient gown. Allow for patient privacy while changing.

4 Position the patient on the exam table in the lithotomy position with a drape to cover her (see figure 6-3).

921les06_img_4.jpg (25290 bytes)

Figure 6-3. Patient in the lithotomy position, draped for pelvic exam.

5 Reassure and encourage the patient to relax during the exam. The patient can relax by taking two to three breaths and letting them out slowly through her mouth.
6 Provide wipes so the patient may remove lubricant used during the exam.
7 Allow for patient's privacy when redressing.
8 Clean up room and dispose of used materials properly.
(5) The physician will observe and palpate the patient's breast for abnormalities.
(6) A rectal exam is usually done at the end of the pelvic exam.
(7) Laboratory studies performed are as follows:

(a) CBC, Hgb, or Hct-to detect anemia.

(b) Sickle cell on black women-to identify patients with sickle cell anemia.

(c) VDRL-to identify patients with untreated syphilis.

(d) Rh factor, blood type-to determine if the patient is Rh negative.

(e) Rubella antibody titer-to determine immunity to rubella.

(f) Hepatitis screen-is done if patient history indicated cause for suspicion.

(g) HTLVIII (AIDS)-screening for AIDS may begin as a common part of the initial visit.

(8) Cultures taken at the time of the pelvic exam are as follows:

(a) Papanicolaou (PAP) Smear is done to detect any abnormalities of cell growth.

(b) Gonorrhea culture is done to screen the patient for possible infection to protect herself, her partner, and the fetus.

(c) Herpes simplex culture is done if there is a history or any lesions noted to rule out active herpes.

Basic Patient Teaching Considerations

a. Instruct the patient on the importance of regularly scheduled follow-up visits (following the normal pregnancy).

(1) Once a month until the seventh month.

(2) Every two weeks during the seventh and eight month.

(3) Weekly during the ninth month until delivery.

(4) Patient teaching must continue on each visit.

b. Instruct the patient on the importance of proper nutrition.

(1) A well-nourished mother and baby are thought to be far less the victims of obstetric and prenatal complications, such as:

(a) Preeclampsia.

(b) Prematurity.

(c) Growth retardation.

(d) Significant residual neurologic damage (that is, cerebral palsy, mental deficiency, or behavior disorders in the child).

(2) Guide to good eating-from the six basic food groups daily (see figure 6-4).

(a) Milk, yogurt, and cheese group-2 to 3 servings per day.

(b) Meat, poultry, fish, beans, eggs, and nuts group-2 to 3 servings per day.

(c) Vegetable and fruits-3 to 5 servings of vegetables and 2 to 4 servings of fruits per day.

(d) Breads, cereals, rice and pasta- 6 to 11 servings per day.

(3) Proper weight gain for pregnancy. After an initial loss, the patient will gain 2 to 4 pounds during the first trimester. Expect a gain of a pound per week during the second and third trimesters.

921les06_img_5.jpg (49127 bytes)

Figure 6-4. Four basic food groups.

c. Instruct the patient on the importance of proper rest and sleep.

(1) Pregnancy will cause the patient to tire more easily.

(2) Prevention of fatigue through short rest periods is vital to good health.

(3) The amount of rest or sleep required will vary with the individual and stage of her pregnancy.

d. Instruct the patient on the importance of exercise and fresh air.

(1) The degree will vary according to her condition and stage of pregnancy.

(2) Walking is usually the exercise of choice.

(3) Swimming is an excellent overall exercise program.

e. Instruct the patient on precautions to take during pregnancy.

(1) Decrease smoking or stop altogether if possible.

(2) Restrict or limit alcohol intake.

(3) Avoid children with measles or other contagious diseases.

(4) Do not change kitty litter boxes or eat raw meats to prevent toxoplasmosis.

f. Instruct the patient on potential danger signs of pregnancy that would necessitate her contacting her physician and coming in.

(1) Any vaginal bleeding, regardless of how small, may indicate possible miscarriage or abortion, placenta previa, or placenta abruptio (see figures 6-5 and 6-6).

921les06_img_6.jpg (15982 bytes)

Figure 6-5. Various degrees of placenta previa.

921les06_img_7.jpg (41414 bytes)

Figure 6-6. Various degrees of placenta abruptio.

(2) Symptoms that may indicate preeclampsia. The symptoms are:

(a) Severe continuous headache.

(b) Dimness or blurring of vision.

(c) Swelling of the face or hands, especially when present after resting all night.

(d) Scotoma- lashes of lights or dots before the eyes.

(e) Persistent vomiting.

(f) Sharp pain in the abdomen.

(g) Epigastric pain.

(h) Weight gain greater than 4 pounds in one week.

(i) Chills and fever.

(j) Burning upon urination.

(k) Sudden escape of fluid from the vagina. The patient should report immediately to the physician or the hospital. She should not wait for uterine contractions to start.

(l) Lack of fetal movement over a 24-hour period once "quickening" has been established.

(m) Regular uterine contractions less than 5 minutes apart for an hour for anyone less than 37 weeks pregnancy.