Chapter 12 Nursing Management During Pregnancy Flashcards
Preconception Care
Promotion of the health & well-being of the woman and her partner before pregnancy
Goal of Preconception Care
Identify & modify biomedical, behavioral, & social risks to a woman’s health or pregnancy outcome via prevention & management interventions
Interconception Period
Time between pregnancies when a woman can improve her health status, especially if the prior pregnancy had a poor outcome or adverse events occurred
Focuses on risk-factors that can be modified and/or eliminated prior to conception to optimize birth outcomes
Preconception & Interconception Care
Both should occur any time a heath provider sees a a woman of reproductive age
Primary nursing care for women of child-bearing age should include a routine assessment of the woman’s reproductive goals & planning
Women who could potentially become pregnant should be assessed for preconception or interconception risks
- Women not intending for a pregnancy anytime soon: Preconception care should focus on contraception counseling & optimizing overall health that may be aggravated by pregnancy
Encourage 400-800 mcg of folic acid/day depending on risk profile w/ regular diet & exercise
Immunizations for Pregnant Women:
- Flu vaccine if planning pregnancy during flu season
- Rubella & varicella vaccines, if no evidence of immunity
- Tetanus/diphtheria/pertussis if lacking adult immunity
Guidelines for Preconception & Interconception Care
Individual responsibility across the lifespan: Each woman, man, and couple should be encouraged to have a reproductive life plan.
Consumer awareness: Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts.
Preventive visits: As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.
Interventions for identified risks: Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high-priority interventions (i.e., those with evidence of effectiveness and greatest potential impact).
Interconception care: Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birth weight, or preterm birth).
Prepregnancy check-up: Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy.
Health insurance coverage for women with low incomes: Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care.
Public health programs and strategies: Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.
Research: Increase the evidence base and promote the use of the evidence to improve preconception health.
Monitoring improvements: Maximize public health surveillance and related research mechanisms to monitor preconception health.
General Health History
Immunization status of the woman
Underlying medical conditions, such as cardiovascular, metabolic conditions, and respiratory problems or genetic disorders
Reproductive health data: Pelvic examinations, use of contraceptives, & STIs
Sexuality and sexual practices: Safer-sex practices and body image issues
Nutrition history and present status lifestyle practices including:
- Occupation and recreational activities
- Psychosocial issues: Levels of stress and exposure to abuse and violence
- Medication and drug use including: tobacco use, alcohol, OTC and prescription medications, and illicit drugs
- Support system, including family, friends, and community
Health History: Reason for Seeking Care
The woman commonly comes for prenatal care based on the suspicion that she is pregnant
She may report that she has missed her menstrual period or has had a positive result on a home pregnancy test
Ask the woman for the date of her last normal menstrual period (LMP)
Also ask about any presumptive or probable signs of pregnancy that she might be experiencing
Typically, a urine or blood test to check for evidence of human chorionic gonadotropin (hCG) is done to confirm the pregnancy
Health History: Past Medical History
Ask about the woman’s past medical and surgical history
- Conds that the woman has experienced in the past may be exacerbated or recur
Chronic illnesses, such as diabetes or heart disease, can increase the risk for complications during pregnancy for the woman and her fetus.
Ask about any history of allergies to meds, foods, or environmental substances
Ask about any mental health problems, such as depression or anxiety
- Gather similar information about the woman’s family and her partner.
Ask about her occupation, possible exposure to teratogens, exercise and activity level, recreational patterns (including the use of substances such as alcohol, tobacco, and drugs), use of alternative and complementary therapies, sleep patterns, nutritional habits, and general lifestyle
Ex) If the woman smokes during pregnancy, nicotine in the cigarettes causes vasoconstriction in the mother, leading to reduced placental perfusion.
Health History: Reproductive Health
Includes a menstrual, obstetric, and gynecologic history: Begins w/ a description of the woman’s menstrual cycle
- Including:
- Age at menarche
- # of days in her cycle
- Typical flow characteristics
- Any discomfort experienced
The use of contraception is also important, including when the woman last used it.
For women and their families, this estimated due date (EDD) represents the long-awaited birthday of their child and is a time frame around which many economic and social activities are planned.
- End point date provides:
- Guidance for the timing of specific maternal and fetal testing throughout pregnancy
- Gauges fetal growth parameters,
- Provides well-established timelines for specific interventions in the management of prenatal complication
In fact, critical decisions, such as preterm labor management, timing of postdate induction of labor, and identification of fetal growth restriction (FGR), are all based on the presumed gestational age of the fetus, which is calculated backward from the EDD
Ask the woman the date of her LMP to determine the estimated or EDD.
Nagele’s Rule for Calculating the Estimated Due Date (EDD)
1) Use the first day of the last normal menstrual period
Ex) 10/14/20
2) Subtract 3 from the number of months
Ex) 7/14/20
3) Add 7 to the number of days
Ex) 7/21/20
4) Adjust the year by adding 1 year
Ex) 7/21/21
5) Estimated due date (+ or - 2 weeks)
Ex Result: July 21, 2021
Health Promotion Activities: Preconception Screening
Ensure that the woman’s immunizations are up to date
Create a reproductive life plan to address and outline reproductive needs
Take a thorough history of both partners to identify any medical or genetic conditions that need treatment or a referral to specialists
Identify history of STIs & high-risk sexual practices so they can be modified
Complete a dietary history combined w/nutritional counseling
Gather info regarding exercise and lifestyle practices to encourage daily exercise for well-being & weight maintenance
Stress the importance of taking folic acid to prevent neural tube defects
Urge the woman to achieve optimal weight before a pregnancy
Identify work environment and any needed changes to promote health
What is the focus of prenatal care?
To reduce the risk of adverse health effects for the woman, fetus, & newborn by addressing modifiable risk factors and providing education about having a healthy pregnancy
What is the significance of the initial prenatal visit?
An ideal time to screen for factors that might place the woman and her fetus at risk for problems such as preterm delivery
- Also an optimal time to begin educating the client about changes that will affect her life
Recent research found that delayed initiation of prenatal care was associated with increased rates of NICU admissions
- The opportunity to improve maternal health and reduce adverse newborn outcomes was lost when prenatal care wasn’t sought
What are the 2 methods of prenatal care?
1) Individually
2) Centering
Individual Method of Prenatal Care
The traditional model where a pregnant woman sees her health care provider at specified interims throughout her pregnancy and all visits occur on a one-to-one basis
Centering Method of Prenatal Care
Involves groups of up to a dozen women in similar gestational ages meeting w/ their health care provider for 10 sessions of approximately 1.5 to 2 hours each
How long does the pre-embryonic stage last for?
1st 14 days
How long does the embryonic stage last for?
15 days to 8 weeks
How long does the fetal stage last for?
9 weeks to 40 weeks
What major fetal development milestone occurs at 4 weeks’ gestation?
Fetal heart begins to beat
What major fetal development milestone occurs at 8 weeks’ gestation?
All body organs are formed
8-12 weeks: Fetal heart tones heard by Doppler
What major fetal development milestone occurs at 16 weeks’ gestation?
Baby’s sex can be seen
What major fetal development milestone occurs at 20 weeks’ gestation?
Mother feels movement called quickening
Baby develops regular schedule of sleeping, sucking and kicking
Hands can grasp
Head hair, eyebrows, eyelashes prese
What major fetal development milestone occurs at 24 weeks’ gestation?
Activity increases, Fetal Resp. movements begin
What major fetal development milestone occurs at 28 weeks’ gestation?
Eyes begin to open and close, 2/3 its final size
What major fetal development milestone occurs at 38+ weeks’ gestation?
Baby gets antibodies from mother
What does uncontrolled diabetes put a pregnant woman at risk for?
Spontaneous abortion (Miscarriage)
Fetal anomalies
Preeclampsia
Fetal demise
Macrosomia
Neonatal hypoglycemia
Hyperbilirubinemia
Macrosomia
A newborn w/ excessive weight
Management of Pregnant Patients w/ Diabetes
Keep A1c level lower than 6.5% to reduce the risk of congenital anomalies, preeclampsia, macrosomia, and other complications
Fasting and postprandial self-monitoring of blood glucose are recommended to achieve glycemic control
- Due to increased red blood cell turnover, A1c is slightly lower during pregnancy
- The target A1: Lower than 6% to 7% to prevent hypoglycemia.
The ADA recommends targets for women with type 1 or type 2 diabetes as follows:
- Fasting: lower than 95 mg/dL
- 1-hour postprandial: lower than 140 mg/dL
- 2-hour postprandial: lower than 120 mg/dL
Insulin is the preferred medication for treating hyperglycemia in gestational diabetes as it doesn’t cross the placenta to a measurable extent
If oral hypoglycemic agents are used, they shouldn’t be the first-line therapy since there are no safety data from long-term studies yet
What is the most accurate method of dating a pregnancy?
Typically, a fetal ultrasound
Gravid (G)
State of being pregnant
Gravida/Gravidity
The total # of times a woman has been pregnant, regardless of whether the pregnancy resulted in a termination or if multiple infants were born from a pregnancy
Nulligravida
A woman who has never experienced pregnancy
Primigravida
A woman pregnant for the 1st time
Secundigravida
A woman pregnant for the second time
Multigravida
A woman pregnant for at least the third time
Para
The # of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not), counting multiple births as one birth event
Parity
Refers to the # of pregnancies NOT the # of fetuses, carried to the point of viability, regardless of the outcome
Nullipara (para 0)
A woman who has not produced a viable offspring
Primipara
A woman who has given birth once after a pregnancy of at least 20 weeks, commonly referred to as a “primip” in clinical practice
Multipara
A woman who has had two or more pregnancies of at least 20 weeks’ gestation resulting in viable offspring, commonly referred to as a “multip”
Prepping a Client for a Physical Exam
Instruct the client to undress and put on a gown.
Ask her to empty her bladder, and when doing so, to collect a urine specimen.
- Typically, this specimen is a clean-catch urine specimen that is sent to the laboratory for a urinalysis to detect possible UTIs
Begin the physical examination by obtaining vital signs, including blood pressure, respiratory rate, temperature, and pulse.
- Abnormalities such as an elevated BP may suggest pregestational hypertension, requiring further evaluation
- Abnormalities in pulse rate & respiration require further investigation for possible cardiac or respiratory disease
Measure the client’s ht and wht.
- If the woman weighs less than 100 lb or more than 200 lb or there has been a sudden weight gain, report these findings to the primary care provider; medical treatment or nutritional counseling may be necessary.
Head-to-Toe Exam: Head & Neck
Assess the head and neck area for any previous injuries and sequelae
Evaluate for any limitations in ROM
Palpate for any enlarged lymph nodes or swelling.
Note any edema of the nasal mucosa or hypertrophy of gingival tissue in the mouth; these are typical responses to increased estrogen levels in pregnancy.
Palpate the thyroid gland for enlargement
- Slight enlargement is normal, but marked enlargement may indicate hyperthyroidism, requiring further investigation
Head-to-Toe Exam: Chest
Auscultate heart sounds, noting any abnormalities
- A soft systolic murmur caused by the increase in blood volume may be noted
Anticipate an increase in heart rate by 10 to 15 beats per minute (bpm) (starting between 14 and 20 weeks of pregnancy) secondary to increases in cardiac output and blood volume
- The body adapts to the increase in blood volume with peripheral dilation to maintain BP
Auscultate the chest for breath sounds, which should be clear.
- Note symmetry of chest movement and thoracic breathing patterns.
-> Estrogen promotes relaxation of the ligaments and joints of the ribs with a resulting increase in the anteroposterior chest diameter
- Expect a slight increase in respiratory rate to accommodate the increase in tidal volume and oxygen consumption.
Inspect and palpate the breasts and nipples for symmetry and color
- Increases in estrogen & progesterone and blood supply make the breasts feel full and more nodular with increased sensitivity to touch.
- Blood vessels become more visible and there is an increase in breast size.
- Striae gravidarum may be visible in women with large breasts.
- Darker pigmentation of the nipple and areola is present, along with enlargement of Montgomery glands.
- Colostrum is excreted typically in the third trimester
Striae Garvidarum
Stretch marks
Colostrum
Yellowish secretion that precedes mature breast milk
Head-to-Toe Exam: Abdomen
The appearance of the abdomen depends on the number of weeks of gestation
Inspection: The abdomen enlarges progressively as the fetus grows
- Inspect the abdomen for striae, scars, shape, and size.
- May reveal striae gravidarum and the linea nigra depending on the duration of the pregnancy
Palpation: Abdomen should be round & non-tender
- Decrease in muscle tone due to influence of progesterone
Linea Nigra
A thin brownish-black pigmented line running from the umbilicus to the symphysis pubis
Where can the fundus be palpated at 12 weeks’ gestation?
Can be palpated over the symphysis pubis
