THE ANTEPARTAL PERIOD

BY:Zosi Farah w. Fernandez, RN

Anatomy and Physiology

a. Uterus- Serves as an organ of implantation for the fertilized ovum

that becomes the fetus- Responsible for expulsion of the fetus during childbirth

from the strong muscle contractions as well as menstruation

- Fundal height a. At the level of the sypmphysis at 12-14 weeksb. Rises at 1 cm/week until 36 weeks of gestationc. At the level of umbilicus at 20 weeks

b. Cervix- Goodell’s Sign- Chadwick’s signc. Vagina- Slight acidic pH (4-5) to decrease risk of

infections- Functions include out passage for

menstrual flow from the endometrium of the uterus, the female organ for intercourse, and a passageway for vaginal childbirth

- During pregnancy the mucosa of the vagina may have a bluish violet color, has increased vascularity, and increase vaginal mucus discharge

d. External structure- External genitals organs, or vulva,

include all the structure found externally between the pubis and the perineum

- Structures include the mons pubis, labia majora, labia minora, prepuce, frenulum, fourchette, clitoris and vestibule

e. Ovaries

Photograph of the vulva. 1. Pubic hair (shaved), 2.Clitoral hood, 3. Clitoris, 4. Labia majora, 5. Labia minora (enclosing the Vaginal Opening), 6. Perineum.

e. Placenta- Chorionic villi form and invade the lining of

the uterus where endometrial arteries fill with blood.

- Earliest function is as an endocrine gland to excrete:a. hCGb. hPL

- Metabolic function of placenta:a. Respirationb. Nutritionc. Excretion

- Fetal blood cells can leak into maternal circulation from occasional breaks in the placenta membrane and the mother may develop antibodies to the fetal blood cells.

- Interference with the circulation to the placenta, such as maternal vasoconstriction from hypertension or cocaine or decreased maternal blood pressure or decreased maternal cardiac output, impedes the blood supply to the fetus.

g. Membraneh. Umbilical cord- Two arteries - One vein- Wharton’s jelly- Usually located centrally as the placenta develops from the

chorionic villii. Amniotic fluid- Functions include fetal lung development, protection of

the cord, and allows for normal limb development and development of GI and renal System

j. Cardiovascular System- Vena caval syndrome- Blood volume increases 30-50% during pregnancyk. Gastrointestinal system- Constipation and gastroesophageal reflux

l. Urinary System- Similar relaxation of the urinary tract places the pregnant

client at risk for UTI or pyelonephritis from bacteria ascending from perineum

m. Endocrine system1. Pancreas2. Thyroid3. Pituitaryn. Respiratory system- Increased BMR requires more oxygen for the pregnant

body- Tidal volume and minute ventilation increase until the third

trimester when the large uterus may impede lung expansion

- CO2 output increases, resulting in slight respiratory alkalosis

o. Hematologic system- RBC increased by one-third- Plasma volume increase is greater, resulting in physiologic

anemia of pregnancy- Clotting factors increase in pregnancy, which increase the

client’s risk for blood clotsp. Breastq. Skin- Increased pigmentation- Chloasma- Linea nigra- Striae gravidarum

Chloasma Linea nigra

Striae gravidarum

r. Fetal development1. Fertilization2. Implantation3. Placental development4. Developmental landmarks

a. Fetal heart tonesb. Quickening

5. Infants at genetic risk of abnormalitiesa. African American: sickle cell diseaseb. Jewish ethnicity of Northern European descent: Tay-sachs

diseasec. Mediterranean: Thalassemiad. Family history of hereditary condition such as cystiic fibrosis

or cleft lip palatee. Born to a woman of advanced maternal agef. Parents are closely related blood relatives

6. Chromosomal abnormalitiesa. Types of transmission to the fetus:1. Autosomal dominant2. Autosomal recessive3. Sex-linked transmissionb. Down syndrome- Risk increases in women over 35

years old and continues to increases with each year of age

- Characteristics:Low-set ears, large fat pads at the nape of a short neck, protruding tongue, small mouth and high palate, epicanthal folds and slanted eyes, small rounded head with flattened occiput, hypotonic muscle with hypermonility of joints, simian crease across the palm of hand and mental retardation

c. Turner’s syndromeCharacteristics:• Usually infertile• Small stature• Cognitive functions

unimpaired

d. Klinefelter’s syndromeCharacteristics:

* usually infetrille* cognitive functions vary from unimpaired to mild mental retardation

e. Inborn errors of metabolism1. Phenylketonuria (PKU)2. Tay-sachs disease3. Cystic fibrosis4. Congenital adrenal hyperplasia5. Congenital hypothyroidism

Assessment

A. Prenatal care1. Assessment of positive pregnancy

Types of Assessment Signs Clinical Manifestation

Presumptive Amenorrhea, breast changes and tenderness, chadwick’s sign, skin changes, abdominal enlargement

Nausea and vomiting, urinary frequency, weight gain, constipation, fatigue, feeling of fetal movement, breast tenderness

Probable Softening of the uterine isthmus, Goodell’s sign, Braxton-Hicks sign, positive hCG on lab test

Same as for presumptive sign

Positive Fetal heartbeat, fetal movement felt by examiner, fetal outline on sonogram

Same as for presumptive sign

2. Naegele’s rule- To determine the estimated date of confinement or estimated

date of delivery, count back 3 months from the first day of the last menstrual cycle and then add1 year and 7 days

3. Obstetrical classificationa. Grvidab. Para or parityc. G-T-P-A-L4. Frequency and elements of maternal and fetal assessmentd. Initial visita.1 Intake assessmenta.2 Lab evaluationa.3 Client educationb. Period specific evaluation in pregnancyb.1 Every 4 weeks until 28 weeks AOGb.2 5-20 weeks of gestation:Maternal alpha-feto protein, begin preterm birth prevention

education and review warning signsb.3 20-24 weeks of gestation:Preterm prevention education

b.4 24-28 weeks of gestation:1 hour glucose tolerance test, cervical exam, begin education

and treatment if diabetic, and review preterm birth prevention and warning signs

b.5 every 2 weeks from 28 to 36 weeks of gestationb.6 28-36 weeks of gestation:CBC, blood group antibody screen if Rh negative, give Rh

immune globulin; cervical examination, follow up with a dietician if diabetic, breast assessment and education preparation for breastfeeding, review of warning sign, and begin parenting class

b.7 35-37 weeks of gestation:Vaginal and rectal group B beta strep cultureb.8 weekly visits from 36 weeks of gestation until deliveryb.9 36-40 weeks of gestation:CBC, repeat gonorrhea, chlamydia, RPR,HIV, hepatitis B screen

if indicated, educate about sign of labor and begin childbirth preparation

5. Assessment of psychosocial aspect of pregnancya. Economic statusb. Marital statusc. Aged. Perceived supporte. Self-esteemf. Cultureg. Religion and importance of faith beliefsh. Stability of living conditioni. Assess mood

i.1 ambivalencei.2 Increased sensitivity and irritabilityi.3 sense of vulnerabilityi.4 fear

j. Assess developmental task of pregnancy1. Pregnancy validation2. Fetal embodiment3. Fetal distinction4. role transition

B. Assessment of High-Risk Pregnancy

1. Health history2. Social history3. Problems with pregnancy4. Physical exama. Inspectionb. Auscultationc. Palpitationd. Vital signs

Diagnostic Studies

a. Sterile Speculum Exam- Indicated for suspected ruptured membranes- Amniotic fluid will turn Nitrazine paper blue because of the

alkaline pH- Free flow of fluid may be seen coming through the cervix

when the clients is asked to cough or perform a valsalva maneuver

Preprocedure:a. Client is assisted into the lithotomy positionb. Gather supplies

b. Urinalysis with reagent strips- Urine is tested with a reagent strip to test for the presence of

components in the urine such as WBC, blood, protein, bilirubin, leukocytes, ketones, glucose, specific gravity, pH, urobilinogen and nitrite.

Preprocedure1. Instruct the client not to discard urinePostprocedure2. Compare the result with the legend on the side of the bottle to

determine normal or abnormal findings3. Discard the urine and record the result

c. 24 hour Urine- The clients total urine output for 24 hours is collected and analyzed

for amount, specific gravity, pH, presence and amount of protein and creatinine clearance.

Preprocedure1. Instruct the client not to discard any urine for 24 hours2. Obtain specimen on ice for the duration of the test3. Have the client empty the bladder and record the start time4. Post sign in the bathroom to remind the client, family, and all staff

that the test is in progress

Postprocedure:1. Send the entire specimen to the lab2. Record the end time

d. Urinalysis and culture- They are useful in determining the presence of a UTI, which during

pregnancy can result in preterm laborPreprocedure1. Obtain the specimen as ordered2. Lable the specimen and send it to the lab

e. Laboratory Serum Evaluation3. CBC4. Metabolic panel5. Liver proofile6. D-dimer and fibrinogen7. Kleinhauer-Betke8. C-reactive protein (CRP)9. Beta hCG10. Maternal serum alpha-fetoprotein (AFP or MS-AFP)11. OB panel12. TORCH

f. Fetal Fibronectin- A protein found in amniotic fluid, the placental tissue itself and

following injury to membranes-either mechanical or inflammatory- Used to gauge the risk of preterm birth for client hospitalized

with PTLPreprocedure:1. Assist the client in assuming the lithotomy position 2. Gather the equipmentsg. Oral glucose tolerance test (OGTT or GTT)- Blood glucose greater than or equal to 140 indicates an abnormal

screen, and the 3 hour GTT is indicated- 3-hour GTT: 100 grams of glucose is given to the client to drink in

a liquid form in 5 minutes; fasting is now required for 12 hours before the test as well as for 3 hours after, serum glucose levels are evaluated at 1,2, and 3 hours after drinking the glucose solution

Preprocedure:1. Obtain the glucose solution and arrange for the blood draw on

schedule

h. Daily Fetal Movement count- Advised to do daily or twice

daily in high-risk client- Counting 10 movements in

1hour is reassuring kick count

i. Electronic fetal monitoring (EFM)

j. Ultrasound- Ultrasound scanning can

be either transvaginally or transabdominally

- Indication for antepartum care include estimation of fetal age, fetal weight and fetal presentation, placenta position and integrity, or a follow-up of fetal anomalies or well being

k. Biophysical Profile (BPP)

Variable Score 2 Score 0

Fetal breathing movements The presence of sustained fetal breathing, movements for at least 30 seconds in 30 minutes of observation

Less than 30 seconds of fetal movement on 30 minutes of observation

Fetal movements Three or more gross body movements in 30 minutes of observation

Less than movements in 30 minutes of observation three gross body

Fetal tone At least one episode of motion of a limb from position of flexion to extension and rapid return to flexion

Semilimb extension or full-limb extension without return or slow return to flexion; or absence of movements

Fetal reactivity Two or more fetal heart rate accelerations of at least 15 beats per minute lasting at least 15 seconds; associated with fetal movement

No acceleration or less than two acceleration of fetal heart rate in 20 minutes of observation

Amniotic fluid volume Pocket of amniotic fluid that measures at least 2 cm in two perpendicular planes

Largest pockets of amniotic fluid measures < 2 cm in two perpendicular planes

l. Umbilical artery doppler Velocimerty- Noninvasive test is done via ultrasound, examining the umbilical

artery- Test is done when placenta/fetal perfusion compromise is

suspectedm. Amniocentesis- Amniotic fluid is then removed for the following indicators:

*genetic screening* diagnostic for isoimmunization*follow-up after an abnormal ultrasound* to evaluate fetal lung maturity* to evaluate for subclinical infection* or to aspirate amniotic fluid to reduce volume

Preprocedure1. Written consent discussion must take place between the client

and the physician2. Educate the client about the procedurePostprocedure3. EFM for minimum of 30 minutes4. Give Rh immune globulin for women who are Rh negative

n. Group B Beta Streptococcus (GSBBS) Culture - Universal screening at 35-37 weeks of gestation- Indicated for clients hospitalized preterm with high-risk

pregnancy condition

Nursing Diagnosis

• Deficient Knowledge• Acute pain• Risk for constipation• Disturbed body image• Ineffective coping• Risk for deficient fluid volume• Noncompliance• Anxiety• Imbalanced nutrition: less than body

requirements

Normal pregnancya. 40 lunar weeks gestationb. Term pregnancy is from the beginning of the 38th weeks until the

completion of 42 weeks.c. Normal concerns of pregnancy1. Nausea and vomiting2. Breast tenderness3. Urinary frequency4. Constipation and hemorrhoids5. Light headedness or dizziness6. Leg cramps7. Fatigue8. Heartburn9. Backaches10. Emotional reactions11. Sexuality and intimacy

High Risk Pregnancy Condition

I. Preterm labor - Progressive dilatation or effacement of the cervix with

uterine contraction or cervical dilatation greater than or equal to 2 cm or cervical effacement of greater than 80% between 20 and 37 weeks of gestation with intact membranes.

- Risk factors for PTL:• African-American race• Young or advanced maternal age• Low socioeconomic status• History of previous PTB• Multiple pregnancy losses or abortion• Uterine or cervical anomalies• Infection• Incompetent cervix• Bleeding during pregnancy• Multiple pregnancy• PROM• Smoking or substance abuse

- Assessmenta. Careful historyb. Uterine contractionsc. Feeling that the baby is balling up and relaxingd. Rhythmic backpain, thigh pain and change in vaginal mucus

- Diagnostic testa. EFMb. Vaginal ultrasoundc. Fetal fibronectin- Medical-surgical managementa. Hospitalizationb. Antenatal glucocorticoids for promotion of fetal lung

maturityc. Tocolytic therapyd. Prophylactic IV antibiotics

- Nursing interventionsa. Encourage hydrationb. Monitor for contractions with EFM and by hand palpationc. Monitor maternal vital signsd. Provide comfort measures and emotional supporte. Report the changes to the physicianf. Obtain lab specimen as orderedg. Encourage bed rest and side-lying positionh. Prepare the client and family for possible diagnostic

procedures and testsi. Instruct the client about early clinical manifestation j. Perform kick counts for contractionk. Perform a digital cervical exam

II. Incompetent cervix- May result in spontaneous abortion or preterm delivery- Complications include PTB, PROM and intrauterine infection

or chorioamnionitisAssessment- Effacement and dilatation of the cervix not associated with

pain or uterine contractionDiagnostic tests- Similar to PTL, excluding fetal fibronectinMedical-surgical management- Cervical cerclageNursing intervention- Evaluate for contractions- Evaluate cervical changes through a digital rectal exam or

vaginal sonogram- Assess lab values and clinical picture for infectious process

III. Premature Rupture of MembraneComplications include risks to the mother and risks to the

fetus;1. Risk to the mother include sepsis secondary to

chorioaminionitis, postpartum endometritis, placental abruption and death

2. Risk to the fetus include umbilical cord prolapse, meconium aspiration, infection or sepsis, skeletal compression deformities, abruption, death, onset of labor/prematurity and possibly cerebral palsy secondary to chrorioamnimitis

Diagnostic testa. Ultrasoundb. BPPc. Serial lab testd. Amniocentesis

Medical-surgical managementa. Prophhylactic antibioticb. Antenatal glucocorticoidsc. Induction of labord. Emergency CS e. Close observation for complicationNursing interventionf. Medicate as prescribeg. Encourage bed resth. Encourage hydrationi. Monitor maternal vital signj. Monitor intake and outputk. Provide comfort measures and supportl. Encourage side-lying positionm. Assess for contractionn. Palpate the abdomen and uterus for tendernesso. Ask the client about painp. Monitor FHR pattern

IV. Diabetes in Pregnancy- Oral hypoglcemia are contraindicated in pregnancy- Maternal complication include increased risk for the mother

developing DM later in life if GDM and fetal complications include risk to pregnancy such as macrosomia, stillbirth, organ malformation,pre-eclampsia, and increased chance of operative delivery

Diagnostic testa. OGTTb. Screen at first prenatal if client has any riskNursing interventionc. Provide the client with an appropriate dietd. Instruct the nature of diseasee. Encourage hydrationf. Encourage side-lyingg. Blood glucose readingh. Administer insulini. Encourage the client to monitor fetal movementj. Ask about risk factors

V. Vaginal bleeding from abruptio placenta- Is premature separation of the normally implanted placenta

from the uterine wall- Associated causes and risk include cocaine, trauma, sudden

decompression of the uterine cavity as in PROM, maternal hypertension, cigarette smoking, advanced maternal age and multiparity

Assessmenta. Severe abdominal pain b. Painful hard abdomenc. Fetal distressDiagnostic testd. D-dimer and fibrinogene. UltrasoundNursing interventionf. Monitor vital signg. Assess fetal status with EFMh. Assess the clients blood type and Rh factors, gestational

age, amount of bleeding, painful or painless bleeding, and presence of other medical conditions

d. Obtain IV accesse. Prepare for emergency CSf. Administer IV fluids bolus or blood transfusion as orderedg. Provide lab specimenh. Provide emotional support to the client and familyi. Clarify question s to help differentiate between previa and

abruption; labor contractionj. Avoid performing a vaginal examk. Palpate the abdomen for hard, board like texturel. Estimate blood loss

VI. Vaginal bleeding from Placenta Previa

- Placenta is covering or encroaching on the internal os to varying degrees

1. Total placenta previa or complete previa

2. Partial placenta previa3. Marginal placenta previa4. Low-lying placenta

- Risk factors include advanced maternal age, mutiparity, African or Asian ethnic background, prior placenta previa, smoking, one or more previous CS delivery and cocaine use.

Assessment- Sudden onset of painless vaginal bleeding Nursing interventiona. Prepare the client for an emergency CSb. Place the client on bed restc. Perform intermittent EFM for onset of labor and fetal well

beingd. Administer antenatal steroide. Encourage side-lyingf. Provide the client and family educationg. Maintain IV access

VII. Pregnancy induced hypertension- Complex disease process with physiologic effects ranging

from hypertension to multiorgan failure- May progress into HELLP syndrome with liver involvement

and platelet destruction, which life is threatening, or seizure from cerebral edema

- Risk factors for developing PIH include first preganancy, older than 40 years old, African-american race, DM, twin pregnancy, family history of PIH, antiphospholipids antibody syndrome, and chronic hypertension or renal problem

Assessment- Headache- Visual changes- Right upper quadrant pain- Epigastric pain- Nausea and vomiting

Diagnostic testa. 24 hour urine b. CBCc. Labs d. Ultrasound e. Biophysical profilef. Umbilical artery doppler studiesNursing Interventiong. Promote bed resth. Perform frequent assessments of maternal hemodynamics, lung sounds, urine

output, reflexes, symptoms or neurologic irritability and fetal well-beingi. Encourage hydrationj. Decrease stimulus k. Monitor blood pressurel. Test in urinem. Inspect for edeman. Perform deep tendon reflexo. Palpate for liver tendernessp. Auscultate lung soundq. Measure intake and outputr. Administer magnesium sulfates. Prepare for dexamethasonet. Provide steroid prophylaxisu. Inform that surgical delivery is like

VIII. Hyperemesis Gravidarum- Nausea and vomiting are common in pregnancy due to

hormones of pregnancy- Criteria for the disorder are met with 5% weight loss along with

dehydration, electrolyte imbalance, ketosis, and acetanuria- Risk factors include young maternal age, obese, nonsmoker,

multifetal pregnancy and molar pregnancy- Maternal complication include decreased maternal weight gain

and electrolyte imbalance, and fetal complications include decreased fetal weight with an increased mortality rate

Nursing interventiona. Provide small, frequent meals, as tolerated, after an intial

period of NPOb. Administer IV hydrationc. Monitor intake and outputd. Administer antiemetics as orderede. Provide parenteral nutrition via central linef. Monitor daily weight

IX. Heart disease- The cardiac disease is classified by the level of functional

capacity- Most common complication is heart failure- The prognosis for the pregnancy and plan of care depend on the

degree of cardiac compromiseAssessmenta. Edemab. Poor oxygenationc. Tachycardia, murmurs, chest pain, and irregular pulseNursing Interventiond. Monitor the client for sign of cardiac overload throughout

pregnancy e. Evaluate fetal well-being f. Instruct the client as follow: avoid excessive weight gain and

emotional stress, report any sign of infection promptly and avoid anemia with adequate nutrition and supplement

g. Avoid anemiah. Administer prophylactic antibiotici. Administer prescribe diureticj. Treat dysrhythmias and use cardiac glycosides

x. Substance Abuse- Substance include alcohol, tobacco, marijuana, cocaine,

and heroinDiagnostic test-toxicology screening of urine for drugsNursing interventiona. Support all the clients efforts to decrease substance useb. Monitor the fetal complicationc. Screen client for use of substanced. Encourage the client to disclose all substance and amount

used e. Monitor for maternal complicationsf. Promotes a slow withdrawal during pregnancy

XI. HIV- AIDS is cause by HIV where the classic symptoms surround

the severly impaired immune system and devastating opportunistic infections

- Antiretroviral drugs that control replication of the virus are given to the client

Assessmenta. Flu-like syndromeb. Night sweatsc. Chronic diarrhead. Recurrent headachese. External fatiguef. Oral hairy leukoplakiaDiagnostic testg. ELISAh. Western blot

Nursing intervention:a. Maintain a nonjudmental attitudeb. Offer emotional support and counselling as neededc. Monitor the client for presence of infectiond. Implement universal precautione. Instruct the client about the need for antiretroviral

medicationsf. Prepare the client for the need to formula feed the infantg. Monitor for fetal well-beingh. Evaluate for other sexually transmitted diseases and

hepatitis Bi. Monitor the progress of vital status or disease state with

lab test

XII. Ectopic Pregnancy- Fertilized ovum implants outside the uterus- Risk factors include tubal sugery leading to scarring and

narrowing, infections in the tubes, pelvic inflammation disease (PID) and IUD contraceptive device

Assessmenta. Vaginal bleedingb. Abdominal painc. HypotensionDiagnostic Testd. B-hCGe. UltrasoundNursing Interventionf. Monitor for sign of hemodynamic instability and shockg. Start an 18 gauge IV, have oxygen available and prepare

the client for surgeryh. Allow the client and her family i. Administer RhoGAM for appropriate client

XIII. Hydatiform Mole- Also called gestational trophoblastic disease- It can develop into choriocarcinoma or into malignant trophoblastic

diseaseAssessmenta. Will have positive pregnancy clinical manifestation but abnormal

lab valuesb. Excessive nausea and vomitingc. Ultrasound has classic “snowstorm” patternd. May have vaginal bleeding or pass parts of the moleDiagnostic teste. B-hCG and alpha-fetoproteinf. UltrasoundNursing Interventiong. Assess client with very high B-hCG levelh. Assist with the evacuation of the molei. Assist the evacuation of the molej. Allow the client and family to grievek. Administer RhoGAM for appropriate clientl. Instruct client on the importance of follow-up in the next yearm. Instruct the client on contraception for the next year

XIV. Spontaneous Abortion- Unplanned pregnancy loss before 20 weeks of gestation- Also referred to as a miscarriage

Classification Description

Threatened Abortion Vaginal bleeding through a closed cervix, possible cramping

Inevitable abortion Vaginal bleeding and uterine cramping are accompanied by cervical dilatation

Incomplete abortion Vaginal bleeding and uterine cramping result in expulsion of part of the products of conception

Complete abortion Vaginal bleeding and uterine cramping result in expulsion of all the products of conception

Missed abortion Fetus had died in utero but has not been expelled

Assessmenta. Vaginal bleedingb. Passage of clots or tissuec. Uterine crampingd. Declining B-hCG levele. Absence of fetal heart tone or absence of fetal movementDiagnostic testf. FHR dopplerg. Possibly ultrasoundh. Lab valuesi. B-hCGNursing interventionsj. Monitor for maternal blood loss and hemodynamick. Prepare the client for sugeryl. Medicate for painm. Allow the client and family to grieven. Administer RhoGAM to appropriate clientso. Advice bed restp. Evacuate the uterus for incomplete and missed abortion