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Chapter 5
Health Care and Fetal Assessment
During Pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
1
Preconception/Prenatal Care
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Objectives




Define key terms listed.
Discuss the concept of preconception care.
Explain the significance of prenatal care.
Outline the care given during the initial
prenatal visit.
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3
Objectives (cont.)


Review care given on subsequent prenatal
visits.
Explain five factors that place the fetus at risk.
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Preconception Care


Health care and screening conducted before
pregnancy occurs so that medical risk factors
or lifestyle behaviors can be identified,
managed, or changed before conception
Best achieved when a pregnancy is planned
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Importance of
Preconception Care


Many women do not realize they are
pregnant for the first 8 weeks
Most birth defects occur between the 2nd and
8th weeks of gestation
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Teaching in Preconception Care

If teaching is missed, the woman may not
know to

Take folic acid
 Update immunizations before conception
 Cease smoking
 Treat current infections
 Obtain genetic counseling or testing
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Prenatal Care


Reduces infant and maternal morbidity and
mortality
Primary focus is education for self-care
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Goals of Prenatal Care

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Ensuring safe birth
Teaching healthy habits
Teaching self-care
Providing physical assessment and care
Preparing parents for adaptation to
parenthood
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Collaborative Care

Involves the patient, the nurse, and other
members of the health care team
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Cultural Competence


Awareness of, acceptance of, and respect for
beliefs, values, traditions, and practices that
are different from one’s own
Adapt health care so it does not violate the
culture or religion of the patient

Provide interpreter
 Adapt teaching (prenatal classes, etc. to
accommodate differences)
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Prenatal Visits


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Initial assessment
To establish relationship among pregnant
woman, nurse, and health care provider
Planned, purposeful communication
Obtain patient’s subjective information about
health status and pregnancy
 Obtain nursing objective assessment
• Posture, facial expressions, physical/emotional signs

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Initial Health and Social History


Personal information, including cultural and
social
Medical history of woman and her family
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Obstetric history
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Nutritional history
Includes use of self-medication, CAM, alcohol
Number of previous pregnancies, birth weights,
length of labor, attitude toward pregnancy,
problems, etc.
Perception of pregnancy


Coping mechanisms
Family support
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Physical Examination



All body systems
Baseline weight and blood pressure
Pelvic examination

Status of reproductive organs/birth canal
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Subsequent Prenatal Visits

Uneventful pregnancy
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Every month for 7 months
Every 2 weeks during the 8th month
Every week during 9th month
Each visit may include


Weight and vital signs
Urine checked for protein, acetone, and glucose
• Enable early detection of HTN, gestational diabetes
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Leopold’s Maneuvers

Used to determine
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What is in fundus
Location of the fetal back
What part of fetus is above symphysis pubis
Position of the cephalic prominence
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Audience Response System
Question 1
The goals of prenatal care include: (select all
that apply):
A.
B.
C.
D.
Ensuring safe birth
Updating immunizations
Teaching self-care
Providing physical assessment and care
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17
Prenatal Fetal Assessment
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Objectives



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Describe four methods of assessing the fetal
condition during the antepartum period.
Explain the uses of ultrasonography during
pregnancy.
Explain the uses of amniocentesis as a
diagnostic tool.
Compare chorionic villi sampling with
amniocentesis.
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Objectives (cont.)


Explain the biophysical profile.
Describe the purpose of the nonstress test.
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Prenatal Fetal Assessment

Emphasis is placed on the safe birth of
infants so that they can develop to their
maximum potential
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Antepartum Fetal Test

Before any test, parent should know
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
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What information will the test provide that is not
already known?
How will the information be used in the
management of the pregnancy?
What are the risks?
If an abnormal condition is detected, is treatment
available?
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Diagnostic Techniques:
Nursing Considerations
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Ultrasonography
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Amniocentesis
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Cordocentesis
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Test Results

Clarifying and interpreting results should be
carried out collaboratively by all health care
providers involved in the procedure
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Psychological Reactions
to Diagnostic Testing

Some look forward to ultrasound because
they can
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Learn sex of fetus
See fetus and movement
Hear heartbeat
Some tests can provoke fear
Allow time for the woman to ask questions
and receive answers
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Audience Response System
Question 2
What test is performed in the second trimester
to identify gestational diabetes?
A.
B.
C.
D.
Hemoglobin A1C level
Complete blood count
Glucose tolerance test
Antepartum fetal exam
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Patient Teaching and Common
Discomforts of Pregnancy
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Objectives



Determine the causes of common discomforts
during pregnancy and the appropriate
measures to alleviate them.
Demonstrate three exercises to strengthen
and stretch muscles in preparation for
childbirth.
Outline four safety precautions for exercising
during pregnancy.
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Objectives (cont.)

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Discuss the suggested dietary alterations
during pregnancy.
Discuss the benefits and limitations of
immunizations during pregnancy.
Individualize the suggested dietary alterations
during pregnancy.
Describe a common pica substance ingested
by a pregnant woman.
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Objectives (cont.)


Identify the basic philosophy of preparation
for childbirth.
Illustrate three different breathing patterns
used during labor and birth.
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Teaching Self-Care for Common
Discomforts of Pregnancy
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
Common discomforts of pregnancy
By trimester

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Influencing factors
Self-care measures or actions to alleviate them
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Bathing During Pregnancy
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Typically perspire profusely
Showering is safer due to ease of access
Hot tubs, Jacuzzi, saunas are contraindicated


Increased body temperature
Tub baths contraindicated when amniotic
membranes have ruptured
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Physical Activity and Exercise

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Goal is to maintain fitness, not improve
fitness or lose weight
Mild to moderate exercise is beneficial
Nurse provides guidance based on


Maternal cardiac status
Fetoplacental reserve
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While Exercising

The woman should not
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Lie supine
Twist
Bounce
Make jerky movements
Become overheated
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Helpful Exercises and
Prenatal Yoga
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Exercises

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Pelvic tilt
Squatting
Kegel
Prenatal yoga


Assists in centering, stretching, breath awareness
and control
Bikram (hot) yoga and Ashtanga (vigorous) yoga
are not recommended during pregnancy
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Effects of Exercise on the Body
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Increases workload of heart
Increases catecholamine levels
Strenuous and prolonged
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Distributes blood to skeletal muscles and skin
Moves blood away from viscera and uterus
Increases maternal hematocrit levels and uterine
oxygen uptake
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Sexual Activity During Pregnancy




In a healthy pregnancy, no valid reason to
limit
Should not engage in activity if amniotic sac
(“bag of waters”) has ruptured or labor has
begun
Alternative positions
Increased uterine activity sometimes noted
after intercourse
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Douching



Changes vaginal pH
Alters normal vaginal flora
Only perform if ordered by health care
provider
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Clothing
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Should be
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Adjustable
Loose
Washable
Lightweight
Dresses and tops should hang from shoulders
and allow for abdominal enlargement
Avoid wearing knee-high or thigh-high stockings
or socks
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Breast and Nipple Care

No soap on nipple area
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Breasts may secrete colostrum
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Removes natural oils provided by Montgomery’s
glands
Breast pads may be needed
Supportive bra
Size has nothing to do with amount of milk
that will or can be produced
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Dental Care
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Can continue routine dental care during
pregnancy
Soft toothbrush will lessen bleeding from gums
Estrogen levels can cause hyperplasia of gums
Xerostomia (dry mouth)
Ptyalism (excessive saliva production)
Periodontal disease increases risk for preterm
delivery or low-birthweight infant
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Immunizations During Pregnancy

Should not receive some attenuated live
viruses while pregnant
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Can be teratogenic to developing fetus
Pregnant woman can receive a tetanus
booster if she has not received one in past 10
years
If she has never had a tetanus vaccine, it can
be given in the second trimester
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Immunizations
During Pregnancy (cont.)


Influenza vaccine can be given in second and
third trimesters
Hepatitis B vaccine can be given during
pregnancy


Contains noninfectious HBsAg particles
Woman cannot receive vaccine if she has an
allergy to yeast
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Contraindications to Vaccination

While pregnant, a woman should not receive


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

Pneumococcal
Hepatitis A
Polio (oral and inactivated)
Measles, mumps, rubella (MMR)
Varicella (chickenpox)
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Employment During Pregnancy


Typically no reason for the woman not to
continue working
Needs to take frequent rest periods and avoid
heavy lifting
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If woman has a job that involves heavy lifting, should
see if modifications can be made
If in a sedentary job, should not stand or sit for a long
time
Movement is important
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Travel During Pregnancy
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
Avoid prolonged sitting
Seatbelts should go across the pelvic bones,
not across the abdomen
Should take copy of health records in case of
unexpected complications
Know what potential risks are in the area
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49
Medications


Only take those drugs prescribed or approved
by the health care provider
Over-the-counter drugs should also be
cleared with the health care provider
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Danger Signs

Woman should be given written instructions,
at the level she can read, listing important
signs to report to the health care provider
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51
Weight Gain and Fetal Growth
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Underweight or small weight gain increases
risk for low birthweight, prematurity, low
Apgar scores, and morbidity
Accepted maternal weight gain

25 to 35 lbs (11.5 to 16 kg)
• First trimester: 3 lbs (1.3 kg)
• Second and third trimesters: 1 lb (0.45 kg) per week
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Nutrition


Status can affect outcome of pregnancy
Obtain complete nutritional history


Include food habits, preferences
Assess nutrition education needs
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MyPlate
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

Provides quick reference for a healthy diet
Well-balanced, nutrient-dense diet combined
with adequate physical activity
To design a personalized well-balanced diet,
go to www.ChooseMyPlate.gov
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Nutritional Requirements During
Pregnancy
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Folic acid and iron supplement
Second and third trimesters: 300 calories
greater than prepregnancy needs
Breastfeeding: increase of 500 calories per
day
1500 to 2000 mL fluid per day
Limit intake of seafood
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Nutrient-Dense Foods

High in nutrients in relation to calories
provided
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Whole-grain breads
Fresh fruits and vegetables
Dried peas and beans
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56
Low-Nutrient Foods


Also called empty calories
Typically sweets and fats
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57
Reading Labels Concerning
Sodium Content
Salt free
Sodium free
<5 mg
Low sodium
<35 mg
Unsalted or no
salt added
No salt added
during processing
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Nutritional Risk Factors
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Adolescence
Short interval between pregnancies
Unusual eating patterns
Previous iron deficiency anemia
Inadequate intake
Low income
Inadequate or sudden weight gain
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59
Pica

Consumption of substances usually
considered inedible and with no nutrient value

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

Cornstarch
Laundry starch
Clay
Ice cubes
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Nutrition and the
Pregnant Adolescent


Social and economic factors
Dual demands




Pregnancy
Adolescence
Tend to eat more “junk food”
Important to include adolescent and person
who purchases and prepares food in nutrition
teaching
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Education and Childbirth

Goal is to help parents and family



Become knowledgeable consumers
Become active participants in maintaining health
during pregnancy and birth
Learn applicable coping strategies to help woman
cope with pregnancy and discomforts
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62
Childbirth Classes

Teach woman and her partner

Relaxation
 Focusing and imagery
 Breathing techniques
 Touch and massage
 Effleurage
 Sacral pressure
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63
Early Prenatal Classes

Focus during first and second trimesters

Early gestational changes
 Self-care
 Fetal development
 Nutrition
 Rest, posture, exercises
 Relief measures for discomforts
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64
Late Prenatal Classes

Focus is on

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

Changes during middle and late pregnancy
Danger signs to report
How to prepare for labor and birth
Includes anticipatory guidance




Birth choices
Postpartum care
Infant care and feeding
Infant safety issues
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65
Breathing Patterns Used
During Labor





Used during contractions
Inspiration and expiration should be equal in
length
Cleansing breath before each contraction
helps woman to relax
“Pant-blow” used in late labor
Expulsive breathing is modified pant-blow
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66
First-Stage Breathing



Slow-paced
Modified-paced
Patterned-paced
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Second-Stage Breathing



Also called expulsion breathing
Open-glottis technique
Important to not hold breath for more than 6
seconds
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68
Audience Response System
Question 3
What immunization should not be given during
pregnancy?
A. Hepatitis B
B. Influenza
C. MMR
D. Td
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69
Review Key Points
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